Home Health ICD-9/ICD-10 Alert

Make sure your documentation is in order or risk claims denials.

When your agency treats a patient with cauda equina syndrome, you're eligible for an additional 20 case mix points. But if you report this code in error when providing care for neurogenic bladder, you put your claims at risk of denial.

Frequent dilemma: Coders often have difficulty coding for 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. For example, neurogenic bladder is mentioned in more than one place in the coding manual. To protect your reimbursement and reputation, you need to understand how to decide which one applies to each patient.

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). Expect the intermediary to downcode your claim if documentation doesn't support this code.

The more commonly used code in home health for neurogenic bladder is 596.54 (Neurogenic bladder  NOS). 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.

Prepare For 344.61 Claim Scrutiny

Regional home health intermediary Cahaba GBA recently reinstated an edit for claims billed with a primary diagnosis of 344.61 because of a sudden increase of claims with this code as a primary diagnosis, a Cahaba spokesperson tells Eli. 

Denial statistics showed a "significant denial rate" for claims billed with a primary diagnosis of 344.61, Cahaba reported in its January 2004 newsletter, during the previous period this edit was active.

Mistake: When you look up neurogenic bladder in the alphabetic index, you'll find two options: 596.54 and 344.61, says Sparkle Sparks, MPT, HCS-D, COS-C, consultant with Redmond, WA-based OASIS Answers. Coders who don't understand the difference between the two codes may choose incorrectly, she says.

Solution: Don't report 344.61 unless you have medical documentation clearly stating that the neurogenic bladder is due to cauda equina syndrome, says Sparks. 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. 

Claims pulled for the Cahaba edit will be checked for documentation above and beyond the ICD-9 code for cauda equina, the spokesperson says. For example: A history of spinal cord injury and pain.

Mistake: Most of the time, claims that list 344.61 as primary include only the narrative of neurogenic bladder or report just a code for catheter changes along with the cauda equina code.

Tip: Take the time to ask the physician and protect your case mix points. Note in the chart that you confirmed the cauda equina with the physician.