Home Health ICD-9/ICD-10 Alert

V57.x as secondary won't result in denied claims.

Still scratching your head over the new V57.x (Care involving use of rehabilitation procedures) coding guidelines? You're not alone. Read on to see expert answers to your most pressing questions.

Code Disease Process For Multiple Therapies

Question: According to the ICD-9-CM Official Guidelines for Coding and Reporting issued by CMS and NCHS, effective Dec. 1, 2005 codes from category V57--which includes physical therapy, occupational therapy and speech-language pathology--can serve only as a principal diagnosis. So what do we do when two or more of these disciplines are required? Do we list them all at the top of our sequencing or do we need to use V57.89 (Multiple training or therapy) so there is no V57.x code in the secondary position?


California Reader

Answer: If multiple therapies are involved, and you truly have a multiple discipline case, then you can report V57.89, says Sparkle Sparks, MPT, HCS-D, COS-C, San Francisco, CA-based consultant with OASIS Answers Inc. The new guidelines mean V57 codes may be placed in M0230 only, so you can't list additional V57 codes in M0240 as secondary. The question is: Are all those therapies in there because they are dealing with a disease or injury? If this is the case, you should code the disease process or the injury or the aftercare code first, says Sparks.

Safeguard Claims With Numerical Diagnoses

Question: Will home health claims be denied if the patient was admitted in the month of November and discharged in December with a V57 code reported as a secondary?


South Dakota Reader

Answer: No, this will not affect your billing and claims will not be denied, says Lisa Selman-Holman, JD, BSN, RN, CHCE, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX. The fiscal intermediaries aren't concerned about the use or placement of V codes for therapy on your claim. They are concerned about the medical necessity of the services you have provided and that is better explained by reporting numerical diagnoses and aftercare codes. The FI will pay your agency based on your HHRG/HIPPS code and the number of therapy visits on your claim, she explains.

Focus On Primary Reason For Home Care

Question: Does this change mean that we need to switch back to always coding therapy first when therapy has more visits?


New York Reader

Answer: No, don't consider the number of visits each discipline has when determining the primary diagnosis; instead, examine the primary reason for home care, Selman-Holman instructs.
Begin by determining the worst problem that the patient has. If the worst problem requires intervention by nursing and therapy then that problem should be coded first. If the worst problem requires only therapy, code therapy first followed by the diagnosis code for the problem, she says.

A V code is only appropriate as a primary diagnosis if you are providing care for a resolving condition or injury, or if you are providing continuous care for a long-term chronic condition, Selman-Holman explains. If the problem is an acute, current diagnosis, code that diagnosis first. In this case, don't include a V code for therapy, she adds.

Drop V57.1 As Secondary

Question: Just a few months ago, we were told we were using the code V57.1 too much as a primary diagnosis. If a patient has more than one service such as physical therapy and skilled nursing services, we were advised to use an after care code such as V54.81 (Aftercare following joint replacement) as the primary code and then to include V57.1 in the list of secondary diagnoses. What do we do now?


Maryland Reader

Answer: In this case, you would still code V54.81 first; but you wouldn't code V57.1 (Other physical therapy), Selman-Holman says. The aftercare is the appropriate diagnosis because both therapy and nursing are providing services as part of the aftercare. As of Dec. 1, V57 can only be coded as primary and it is not appropriate as primary in this situation, she explains.

Re-Think Primary Diagnosis Choice

Question: There have been so many reports of probes and edits regarding claims with V57.1 listed as primary. Doesn't this change to the guidelines put our claims at risk of even greater scrutiny?


Connecticut Reader

Answer: These probes and edits are focused on the medical necessity of therapy, meeting the therapy threshold, and case-mix codes to justify therapy, Selman-Holman says. Perhaps this change will force coders to re-think the coding of the primary diagnosis. V57 has risen to be the primary diagnosis on 25 percent of claims. Much of this increase is because of incorrect coding. The probes and edits can pick up claims based on the HHRG/HIPPS code and the revenue codes for therapy so the change to the coding of therapy will have little effect on the claim edits.