Home Health ICD-9/ICD-10 Alert

Published on Wed Jul 27, 2005 PDF

Test yourself: Do you know the three conditions in which CMS blesses primary symptom codes?

If you automatically turn to symptom codes to justify therapy, you're exhibiting a symptom of coding confusion. Here's what you need to know about symptom codes to ensure proper sequencing for all patients.

Memorize These 3 Rules

The Centers for Medicare & Medicaid Services says home health coders are allowed to list a symptom code as the primary diagnosis in three different scenarios:
 
1. The medical diagnosis is not yet established.
 
2. Using a symptom code will keep you from using an outdated diagnosis.
 
3. The symptom code most accurately portrays the patient.

Scenario #1: The medical diagnosis is not yet established.

"Frequently in home health a patient is admitted without accompanying documentation that would allow the agency to assign a diagnosis code other than a symptom code from Chapter 16 of the ICD-9-CM manual," CMS notes in its home health diagnosis coding guidelines. "If the agency cannot obtain a documented diagnosis by the time the OASIS must be completed, the agency should report the symptom as the primary diagnosis."
 
Home care providers often receive patients who have injured themselves, but they haven't yet completed all the diagnostic tests to find out why, notes Sparkle Sparks, MPT, HCS-D, COS-C, with Fazzi Associates in Naples, FL. In these cases, your best bet is a symptom code that describes why the patient hurt himself.

Example: Disturbance of skin sensation (782.0) is a symptom code home care coders might often find appropriate as a primary diagnosis, says Sparks.
 
"I had a patient once with a really severe burn because she had an alteration of sensation in her hand, which they discovered when she came into the ER after putting her hand on a stove burner without realizing it," Sparks tells Home Health ICD-9 Alert. "When I got her, we didn't know what the definitive diagnosis was," so 782.0 was the best code to use.

Scenario #2: Using a symptom code will keep you from using an outdated diagnosis.

"Symptom codes from Chapter 16 have a potentially important role to play, especially when nursing care and/or rehabilitation is the focus of treatment but no current disease condition is appropriate to report," CMS says. "To avoid coding a diagnosis that was resolved earlier, a symptom code may be the
best choice."
 
Example: Total knee joint replacement patients often are good candidates for symptom codes as primary in this scenario. Say a patient had osteoarthritis in one joint, and then had the joint replaced. Obviously, she no longer has that diagnosis, because the replacement eliminated the arthritic joint, says Sparks. In this case, you'd be more likely to code for weakness or abnormality of gait.
 
Another example of a common outdated diagnosis in home care is urinary tract infection, notes Laresa Boyle, RHIA, director of coding services for Healthcare First in Cushing, OK. Before you code for a UTI, make sure the patient actually still has one.

Scenario #3: The symptom code most accurately portrays the patient.

"When the patient is receiving home care for only one aspect of a chronic condition, and there is no code for the condition that explicitly incorporates the aspect, then a Chapter 16 symptom code may be the best code meeting the HIM-11 requirements to report the primary reason for home care," CMS instructs.

Example: If you have a patient who has Parkinson's disease (332.0), but you're treating her only for abnormality of gait to increase the patient's safety, then you shouldn't list Parkinson's as the primary diagnosis.
 
This example is particularly significant be-cause the Parkinson's code carries 20 case mix points, while abnormality of gait earns you only 11, notes Sparks. "You could be charged with upcoding" if you inappropriately list Parkinson's as the primary reason for home care, she warns.
 
"If you're only treating one aspect of a disease, you should only be coding that one aspect of the disease," instructs Sparks. "It relates back to the whole point of coding, which is that you should be coding from the plan of care."

Note: Never use a symptom code when the symptom is an integral part of the patient's disease process, Sparks reminds providers.
 
For example, don't code for lower extremity edema in a congestive heart patient, Sparks says.