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Home Health ICD-9/ICD-10 Alert

Coding How-To:

Don't Let Symptoms Trip up Your Therapy Coding

Published on Fri Feb 10, 2012

Hint: Uncover the pathology for more accurate diagnoses.

Your therapists may be providing care for a symptom of your patient's condition, but that doesn't mean you should automatically list a diagnosis code for the symptom. Make sure you're accurately reporting your therapy patient's condition by drilling down to the root cause of the functional limitation.

Understand the Nagi Disablement Therapy Model

Familiarizing yourself with the Nagi Disablement Therapy Model can help you to make certain your therapy documentation, OASIS responses, and coding are all in synch, says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, HCS-O, director of coding with Foundation Management Services in Denton, Texas.

Follow the four levels of the Disablement Therapy Model, shown below, to make certain you're listing the appropriate diagnosis codes for your therapy patients:

1. The pathology is the disease, disorder, or condition that the patient has. This is the diagnosis code you should be reporting.

2. The impairment is the consequence of the disease, disorder, or condition. In other words, it's the symptom the patient is experiencing that is caused by the pathology. Most often, it's not necessary to list the impairment if you know the pathology causing it.

3. The functional limitation is the inability to perform a task or action because of the impairment that the pathology has caused. The therapist's documentation of this must be relevant. And the responses to the functional limitation items on the OASIS (ability to dress upper and lower body, bathing, toileting, transferring, and ambulation) should support the therapist's documentation.

4. Disability is a behavior that occurs over time because of persistent functional limitations. This fourth level of the disablement continuum is rarely dealt with in home health because there is no achievable goal.

Avoid the Therapy Diagnosis Trap

One mistake coders make is thinking that they must list a symptom diagnosis for the impairment that therapy is treating. Instead, coders should seek to find out what the pathology is and code for that, Twombly says.

"Always drill down to the cause," says Arlynn Hansell, PT, HCS-D, HCS-O, COS-C clinical excellence program manager at American Mercy Home Care in Cinncinatti, Ohio. "Why does the patient have abnormality of gait? Why is the patient falling? You should be able to land on a definitive diagnosis."

If the documentation isn't specific, don't hesitate to ask for more details, Hansell says. For example, if the focus of care is abnormality of gait and the doctor doesn't say "due to Parkinson's," therapy needs to step up and establish a definitive diagnosis, she says. The documentation should say the impairment "is because" or "due to" something. "What is the underlying problem?"

Coding example: Your agency is providing physical therapy to address abnormality of gait for a patient due to his Parkinson's disease. This is a therapy only-case. For this patient, you would code as follows:
  • M1020a: V57.1 (Care involving other physical therapy) and
  • M1022b: 332.0 (Paralysis agitans).

Providing therapy for a patient with Parkinson's disease is different from addressing abnormality of gait caused by a sedentary lifestyle, Hansell points out. Parkinson's has a neurological component and the patient won't always respond to treatment. So listing 781.2 (Abnormality of gait) rather than 332.0 doesn't really address the care your therapist is providing in this case.

A therapist providing treatment for a Parkinson's patient experiencing abnormality of gait is doing more than just gait training, Twombly says. Don't sell your agency short.

Caution: Don't list 781.2 if it's redundant, Hansell says. With some underlying diagnoses, 781.2 "just takes up space. For example, if your patient has a lower extremity fracture, of course he has abnormality of gait," she says. The same goes for coding muscle weakness in a patient with congestive heart failure. Muscle weakness is generally a result of the CHF, so there's no need to list an additional code for it.

List a Symptom Code for Unknown Pathology

Sometimes you just can't drill down to the pathology for a therapy patient. In these cases, you can list a symptom code.

Generally, you want to find the underlying diagnosis, Hansell says. "She doesn't get around much" should prompt you to dig into what's underneath that. But "occasionally, when you're seeing a patient for weakness, especially during flu season, you can't get past 'he's weak,'" Hansell says. "Sometimes you can't drill down enough."

For example, your patient is sedentary, not going out, not getting up. Therapy is there just to deal with the weakness and abnormality of gait due to a sedentary lifestyle. That's where symptom codes such as 781.2, 728.87 (Muscle weakness [generalized]), and 780.79 (Other malaise and fatigue) come in, Hansell says.

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