Home Health ICD-9/ICD-10 Alert

Take time to confirm the diagnosis to avoid payment delays.

If you deserve the extra points - and cash - for cauda equina syndrome, here's how to get them

One frequent dilemma for coders is how to code bladder problems in patients whose primary care involves catheter changes. Code V53.6 (Fitting and adjustment of urinary devices) is pretty clear. The problems come in coding the underlying reason for the catheter, experts say. For example, neurogenic bladder is mentioned in more than one place in your coding manual. To protect your reimbursement and reputation, you need to understand how to decide which one applies.

Warning: Agencies can expect to see additional documentation requests (ADRs) from their fiscal intermediary when they use case mix code 344.61 (Cauda equina syndrome with neurogenic bladder), warns coding expert Prinny Rose Abraham with HIQM in Minn-eapolis. And the intermediary will downcode your claim if documentation doesn't support this code, she adds.

The more commonly used code in home health for neurogenic bladder is 596.54, experts agree. This is not a case mix code, and doesn't add the extra reimbursement available with 344.61. If the record is unclear about the reason for the catheter, you need more information before coding.

Coding 344.61 for a quadriplegic patient leads to downcoding from regional home health intermediary Cahaba GBA, confirms Louise Rayfield with Jefferson Memorial Hospital Home Care in Crystal City, MO. Switching to 596.54 (Neurogenic bladder NOS) eliminated the ADRs, she tells Eli.

Denial statistics show a "significant denial rate" for claims billed with a primary diagnosis of 344.61, Cahaba reports in its January 2004 newsletter.

Mistake: Problems often arise because inexperienced coders look under 344.0x (Quadriplegia and quadriparesis) for the reason for the bladder dysfunction. They then scan down the column and come to 344.61. Because the code specifically mentions neurogenic bladder, they stop there and use this as the diagnosis, not reading the note that includes the definition of cauda equina syndrome, experts say.
 
Solution: Agencies can't assume a patient's underlying problem is cauda equina even if the patient is a quadriplegic, explains consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates. "It takes more than quadriplegia to document cauda equina," she says. Cauda equina is a very specific and rare disorder that results from compression of spinal nerve roots. Ruptured discs, tumors, infection, fractures or other diseases such as ankylosing spondylitis can cause cauda equina.

Some of the symptoms of cauda equina are dull pain and paresthesias in the sacrum, perineum and bladder, pain radiating down the buttocks, back of thigh, calf and into the foot with a prickling, burning sensation, Abraham instructs.

Tip: Your FI will look for indications in the record that cauda equina really is the cause of a patient's neurogenic bladder. "Physician query is worth the time to protect your assigned case mix points," Abraham says. Note in the chart that you confirmed the cauda equina with the physician, she recommends.

Editor's Note: To see Cahaba's discussion of these coding denials, go to page 24 at
www.iamedicare.com/Provider/newsroom/newslines/010104.pdf.