Home Health ICD-9/ICD-10 Alert

Coding muscle weakness incorrectly is a problem for many agencies

If you're having claims downcoded because you're coding muscle wasting instead of muscle weakness, you're not alone. Double-check your documentation to keep 728.2 and 728.9 from leaving your agency weak in the knees.
 
Think twice before listing 728.2 (Muscular wasting and disuse atrophy, NEC) or 728.9 (Unspecified disorder of muscle, ligament and fascia) as primary, warns fiscal intermediary Cahaba GBA in a recent Medicare A Newsline article. "Inappropriate submission of these ICD-9-CM codes often results in claims being downcoded," Cahaba says.

The basics: Two diagnoses are listed as subterms under 728.2: amyotrophia NOS and myofibrosis. If the physician has noted that a patient has either of these diagnoses, and the primary focus of skilled care is to treat these conditions or NEC muscle wasting, you may use 728.2 as the primary diagnosis.
 
You should list the nonspecific code 728.9 as primary only when "there are no other more specific codes available for the patient's condition," Cahaba reminds coders. Further, this code refers to "an underlying problem with the actual musculoskeletal system," points out consultant Judy Adams, RN, BSN, HCS-D, with Charlotte, NC-based Larson-Allen Health Care Group.
 
"We are expected to code to the highest level of specificity," emphasizes consultant Lynn Yetman, RN, MA, with Reingruber & Co. in St. Petersburg, FL. Contact the physician for a more accurate diagnosis before using 728.9, she advises.

Steer Clear of 728.2 for Temporary Weakness

Many agencies use 728.2 to indicate temporary muscle weakness resulting from non-use after a hospitalization (or general muscle weakness),Cahaba says. But this code is meant to indicate true muscle wasting, not simply muscle weakness, Cahaba makes clear.
 
If the patient hasn't had a long period of inactivity, such as an extended ICU hospitalization, your payor will look askance at the 728.2 code.

Think Twice Before Using 728.2

Test: Use 728.2 only if there is a "measurable decrease in the size of the muscle group involved," Cahaba instructs. This is a sign of actual muscle wasting and disuse atrophy. Check the patient's medical record to compare pre- and post-observations/measurements - this documentation will help support the 728.2 diagnosis.
 
Coders in home care should use this code very rarely, urges Yetman. An example of when you might use it would be after removal of a cast, she offers. "Documentation would be able to show measurable muscle atrophy," she notes.

More likely: In many cases, a code from the 780.7x (Malaise and fatigue) series is more appropriate than 728.2.
 
Many beneficiaries who receive therapy in their homes need it because of the muscle atrophy that often results from the aging process, poor nutrition and inactivity, according to Cahaba.
 
"In the case of generalized weakness, a more specific code of 780.79 (Other malaise and fatigue) is available and should be reported," Cahaba advises. This code includes the diagnosis of "asthenia" - which means "any weakness, lack of strength or loss of energy, especially neuromuscular" - as well as lethargy, postviral (asthenic) syndrome and tiredness. That makes the code a prime candidate in many cases.
 
Snag: Some payors, such as Palmetto GBA, don't include 780.79 on their list of diagnoses that justify therapy, notes Lisa Selman-Holman, JD, BSN, RN, CHCE, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX.

Don't Be Swayed by Case Mix Codes

Agencies often automatically select one of the 728 codes to justify therapy services for patients with muscle weakness because all of these codes are case mix codes, notes Adams. But you can't take this route unless you can prove the code is appropriate.