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Home Health ICD-9/ICD-10 Alert

Reader Question:

Coding Isn't The Issue With This Therapy Claim Denial

Published on Wed Mar 14, 2007

Question: An elderly patient who recently had an episode of flu was referred to our agency for physical therapy because of increased weakness. The evaluation indicated that the patient had general weakness but didn't document any strength measurements. We reported 780.79 (Other malaise and fatigue) as the primary diagnosis, and the therapist provided two visits a week for five weeks for gait and therapeutic exercises. After five weeks, the patient showed no indication of any appreciable progress and the claim was denied as not medically reasonable and necessary. How should we have coded for this patient?

Connecticut Subscriber


Answer: This doesn't appear to be a coding problem. The patient showed no rehab potential. A patient with malaise and fatigue usually gets better with a little assistance or rest -- or he just doesn't get any better.

Documented strength measurements (a beginning strength and an ending strength) may have helped you get reimbursement because you needed to show improvement. Without progress, the care doesn't seem medically necessary. Providing 10 visits was probably excessive. A home exercise program and a few visits would have possibly been paid, or at least kept you out of the therapy edit.

Lesson Learned: Remember, it is the documentation that gets you paid in the end. No matter what you have coded, your documentation is the key.

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