Home Health ICD-9/ICD-10 Alert

Counting the number of visits is not the answer.

To achieve V57.1 accuracy, you may have to unlearn some of the information you thought was correct.

If your supervisor is telling you to cut down on the number of times you use V57.1 (Care involving use of rehabilitation procedures, other physical therapy), you're not alone.

Home health agencies are overusing V57.1, warns home health coding expert Joan Usher with JLU Health Record Systems in Pem-broke, MA. ICD-9-CM coding was designed to provide a numerical value for each diagnosis, which initially served to quantify reasons for death and illness, primarily for research. But now diagnosis coding also affects reimbursement and quality measures. "Coding V57.1 for every therapy admit breaks down the integrity of the data," Usher says.

The most common primary diagnosis in home care is V57.1, coding experts say. In fact, the percentage of cases in which V57.1 is the primary diagnosis continues to rise, reports Seattle-based Outcome Concept Systems. During the first three months of V code use in home health - October through December 2003 - V57.1 accounted for 11 percent of primary diagnoses on OASIS assessments. By the first quarter of 2004, that percentage increased to 20 percent. And in the last quarter of 2004, V57.1 accounts for 25.1 percent of primary diagnoses (based on 250,000 assessments), OCS' Christine Lang tells Eli. 
 
Problem: Diagnosis coding is an evolving process. Coding practices change as home health agencies learn more about how to code, but clinicians and coders often hang onto the strategies they first learned, says Fort Myers, FL-based PT Sparkle Sparks, senior clinical consultant with Fazzi Associates.

For example, at the beginning of the prospective payment system, HHAs had to learn how to choose which of the patient's multiple diagnoses would be considered primary. Many clinicians found security in a very mechanical system: count the visits and whichever discipline had the most visits determines the primary diagnosis.

Then when agencies began using V codes, if PT was scheduled to make the most visits, many automatically entered V57.1 as primary, Sparks says.

This mechanical approach ignores many of the other criteria for choosing the primary diagnosis, Sparks says. The discipline making the most visits is only one consideration, experts stress. 

PT provides therapy for many diagnoses, Sparks notes. Coding V57.1 doesn't reveal what's wrong with the patient, she emphasizes. When you look back at your patient's data sorted by primary diagnosis, all V57.1 will tell you is that the patient needed PT.

Do: Use V57.1 as primary when a home health episode involves PT as the only skilled service, Usher says. But even then, putting the underlying disease or injury as the secondary diagnosis helps you have a complete picture, Sparks adds.

Example: You admit a patient with severe os-teoarthritis, referred by his physician for home care because his ambulation worsened after he discontinued taking Vioxx. He is homebound and will be receiving only PT, for help with ambulation.

Here you would code V57.1 as primary and then in M0240 put 715.xx (Osteoarthrosis and allied disorders) and 719.7 (Difficulty in walking), Sparks says. The order of the codes in M0240 would depend on the plan of care, she adds, although PT is likely to be treating many aspects of the OA. Nothing would go in M0245, because the V code in M0230 does not replace a case mix code (see Eli's Home Health ICD-9 Alert, Nov. 2004, p. 46).

Don't: Just counting visits doesn't work. When you are providing aftercare for a joint replacement, or when the therapist is in the home to treat an exacerbation of multiple sclerosis or cerebral palsy or to treat a patient with a new onset of arthritis, V57.1 is not likely to be the correct primary diagnosis, Usher says. This is true even if PT makes more visits than other disciplines.

Example: In an exacerbation of MS, PT is going in for gait training, nursing is probably teaching new meds and OT will be covering activities of daily living, explains Margaret Rush, OASIS and coding coordinator for Birmingham, AL-based Alacare Home Health & Hospice. In this case, all the disciplines are addressing the MS, so you would code 340 (Multiple sclerosis) in M0230 and in M0240 put V57.1 and V57.21 (Encounter for occupational therapy), Rush says.

Master V57.1 with These 8 Steps
 
Savvy agencies are choosing to address V57.1 overuse before the Centers for Medicare & Medicaid Services does. Cases coded with V57.1 as primary may lead to extra reimbursement, not because of the primary code, but because you often see a case mix code in M0245 when PT is primary, Sparks says.

What to do: Step back and look at your agency's diagnosis coding, experts suggest. If you are overusing V57.1, consider these coding basics to improve accuracy:

1. Review criteria for choosing the primary diagnosis. The primary diagnosis is "that diagnosis which represents the most important reason you're providing home care, the most acute diagnosis and that which justifies the intensity of service," says Pat Sevast with American Express Tax & Business Services in Timonium, MD.

2. Look to coding guidelines. Aftercare codes indicate a reason for care in patients who have been treated for a disease or injury now not present, and who still require care to consolidate the treatment, deal with residuals or prevent recurrence, Usher reminds coders.

3. Don't turn to V codes first. Just because you are now allowed to use V codes as the primary diagnosis, doesn't mean you always have to use them. Use V codes as primary only in cases where you must use aftercare codes to be compliant with coding guidelines, says Mary St. Pierre with the National Association for Home Care & Hospice.

If there is a complication of medical or surgical care, such as infection or wound dehiscence, select a code specific to either condition rather than a V code, CMS instructs.

4. Choose the most specific V code. An aftercare code may describe the home care episode more clearly than V57.1. For example, in a total joint replacement, PT will be very involved. But nursing is probably also ordered for monitoring protimes and doing teaching and observation. Here V54.81 (Aftercare following joint replacement) with V43.64 (Joint replacement, hip) would better explain the plan of care, Sparks suggests.

5. Avoid just coding symptoms. The elderly population agencies see most for home care usually has some sort of gait deviation or balance issue, Sparks says. If patients are not active, they begin to get weaker.

But you must look beyond these symptoms to the underlying cause, especially in a multidisciplinary case, Sparks stresses. Parkinson's and chronic obstructive pulmonary disease may result in weakness and gait problems, but these conditions can also present other issues the therapist must address, she cautions.

6. Gather data on your agency. If you sort all your V57.1 episodes by secondary diagnoses, you'll be able to determine what the usual secondary diagnoses are when V57.1 is primary, Sparks recommends. Then look at whether these codes should actually have been primary. Why is your agency going into the home? For example, are you just providing PT or are you actually providing aftercare for a healing traumatic fracture?

7. Develop a coding compliance process. Coding is not black and white, Sparks reminds coders. As long as you are not violating coding rules and you have sound logic for the codes you chose, "probably your coding will fly," she says. Once you have determined how your agency will treat a specific coding situation, write that down and communicate clearly so everyone codes it the same way.

Creating a coding compliance manual says "here's how we've chosen to code specific scenarios," Sparks says. This gives you something to show anyone who questions your interpretation of coding.

8. Check your documentation. Be sure documentation supports the codes you choose. If your primary diagnosis is an underlying disease process, you can't just provide and document exercises or gait training. You need to document teaching, observation and management of multiple aspects of the disease. Remember to include enough descriptive documentation, especially if you are using point of care software, Sparks warns.