Home Health ICD-9/ICD-10 Alert

Reaching the therapy threshold can send up a red flag on your Parkinson's claims.

At least one fiscal intermediary has edits in place to make sure agencies are coding correctly for Parkinson's disease. Safeguard your claims (and your 20 case mix points) by making certain you've got the documentation backup you need.

Protect your claims: Good documentation is the key to supporting a Parkinson's claim. Regional home health intermediary Cahaba GBA currently has two Parkinson's edits in place and the highest percentage of denials in each is related to medical necessity, says a December 2006 Cahaba Web site posting.

Cahaba's first edit, 5THCD, selects claims with Parkinson's disease as the primary diagnosis, a length of stay greater than 60 days and no billed therapies.

The second edit, 5THBY, also selects claims with Parkinson's disease as the primary diagnosis, and a length of stay greater than 60 days, but also for the therapy threshold of 10 visits or more.
 
Warning: Even if Cahaba isn't your RHHI, these edits point to areas where your claims might be vulnerable.

Read Records Thoroughly Before You Code

To make sure you have a firm grip on what's needed to support a Parkinson's diagnosis in home health, Jun Mapili, PT, MAEd, rehab therapies supervisor with Global Home Care in Troy, MI, offers the following tips:

1. Read everything with an eye for the changes to the patient's medical condition requiring skilled service. Dig into the details on the comprehensive assessments, specifically the body systems, and look for any medical instability the patient may have such as progressive motor impairment causing incoordination of movement.

Look for any disease progression of Park-inson's such as resting tremor, muscle cogwheel rigidity, bradykinesia (slowness in movement), festinating gait. Also keep an eye out for other problems such as fluctuating vital signs, edema, respiratory changes, and weight changes needing skilled care. Clinical interventions related to these changes that will produce significant improvement will be covered as medically reasonable and necessary.
 
2. Find any exacerbation. If the documentation indicates there is a recent exacerbation of Parkinson's disease requiring skilled care, listing 332.0 (Parkinson's disease) as the primary diagnosis is appropriate.

True exacerbations require multiple aspects of care and warrant reporting Parkinson's as primary, thus insuring your agency receives the added reimbursement such a complex case deserves, says Mapili.

Documentation tip: Using a rating scale such as the Unified Parkinson's Disease Rating Scale to trace the progression of a patient with Parkinson's disease can help establish that there is an exacerbation, says Mapili.
 
3. Trace any recent hospitalization before or during the episode of care due to Parkinson's disease. If the patient was just discharged from the hospital (or the patient was transferred to the hospital and later resumed home care), home care is probably necessary to continue the skilled treatment, Mapili says. The hospital won't wait until the patient's problem is resolved to discharge; rather, it'll discharge him to home health when the level of care can be managed by home health professionals, he says.

4. Look for treatment modifications. When admitting or recertifying a case, look for any treatment changes, such as a new medication or change in the medication treatment, that will improve the patient's medical status. Such a change would require observation and assessment for its effectiveness including its side-effects, so listing Parkinson's as primary would be appropriate, Mapili says.

Caution: If the treatment is routine for an old problem with no significant improvement noted, and there is no attempt to change the treatment approach in the recertification, your claim will likely face a denial in medical review, Mapili says.

5. Look for the multiple aspects of care related to Parkinson's disease. Use the code for Parkinson's as primary only if you are treating multiple aspects of the disease, says coding consultant Sparkle Sparks, MPT, HCS-D, COS-C, with Redmond, WA-based OASIS Answers.

Important: You should distinguish between patients receiving multiple aspects of care versus patients whose treatment involves only one aspect of care. For example, when the case has a multiple disciplinary approach, such as physical therapy and skilled nursing, the home health agency is providing multiple aspects of care, Mapili says.

The twist: Multiple aspects of care don't require multiple disciplines. Even in a physical therapy-only case, if the PT is addressing multiple aspects of care for the underlying cause (Parkinson's disease), you can still gain the additional reimbursement that Parkinson's brings, provided the documentation supports your coding, Mapili says.

In a PT-only case, you can list V57.1 (Other physical therapy) first, followed by 332.0. Then, because you used a V code in M0230a, place 332.0 in M0245 for payment calculation.

Exception: If there is an acute exacerbation of the Parkinson's, code the Parkinson's first because acute conditions trump the use of V codes.

Don't overlook: If treatment is directed at only one aspect of care, the proximate diagnosis is most applicable. For example, your patient has Parkinson's disease, but currently, abnormality of gait is your patient's most serious problem and will be the focus of care. Gait training is the only skilled service the therapist will provide.

In this case, 781.2 (Abnormality of gait), which brings 11 case mix points, is the more appropriate than 332.0 for Parkinson's, Mapili says.

Beware: The Parkinson's code earns you 20 case mix points, while abnormality of gait earns you only 11, Sparks notes. "You could be charged with upcoding" if you inappropriately list Parkinson's as the primary reason for home care, she warns.

6. Check the number of visits. Claims for recertified Parkinson's patients with 10 or more therapy visits will be pulled in the Cahaba edit.

If you answered yes to M0825 (Does the care plan ... indicate a need for therapy ... that meets the threshold for a Medicare high-therapy case mix group?), look for documentation that supports extended therapy, Mapili says. Also make sure that the goals would make a significant improvement in the patient's overall function in a reasonable and predictable time, he says.