Home Health ICD-9/ICD-10 Alert

Question: How would you code a patient who was hospitalized due to atrial fibrillation and hypertension? He then went to a skilled nursing facility for some rehab. He is at home now with decreased overall strength, balance, and endurance. We are providing only physical therapy and occupational therapy. Is this a case for abnormal gait or difficulty walking or should it be 728.87 for general muscle weakness (as a result of the hospitalization)?

Answer: The primary diagnosis would be V57.89 (Multiple training or therapy) because the patient was admitted for therapy. Generalized muscle weakness is the most appropriate code for the underlying diagnosis in this case because of the patient's deconditioning.

Difficulty walking (719.7) is only appropriate for gait issues related to chronic conditions of the bone or joint. Abnormality of gait (781.2) is mostly appropriate for neurological issues, although there are certain exceptions. Follow the generalized muscle weakness code with 427.31 (Atrial fibrillation) and 401.9 (Essential hypertension, unspecifed).