Home Health ICD-9/ICD-10 Alert

Published on Wed Jul 27, 2005 PDF

Question: If physical therapy and skilled nursing are both visiting a patient for different reasons, how do you know what should be primary? Would you go by the most intense service?
 
Also, would you ever use V57.1 as the primary diagnosis? If so, when?
 
Answer: The assessing clinician and coder should look beyond just "who has the most visits?" when determining the primary diagnosis when both therapy and nursing are involved. Ask yourself if nursing and therapy are treating related conditions.  
 
For example, say a patient is being seen after a joint replacement. Therapy performs 12 visits, while nursing provides only three visits to remove staples and perform venipuncture for INRs.
 In this case, you should not code PT first because the condition requiring both disciplines is the aftercare of the joint replacement; thus, it is primary.

One step further: If a patient is discharged from the hospital with congestive heart failure (CHF) and requires both nursing and therapy, you might be tempted to code V57.1 (Other physical therapy) as primary, followed by muscle weakness. This approach would garner 11 case mix points because the PT's frequency is higher.
 
Unfortunately, this approach is wrong. The primary focus of the care is the CHF, and the muscle weakness in most cases is the result of the CHF.
 
The pathophysiology of CHF includes the shunting of the blood away from the musculoskeletal system to the heart and brain as the heart decompensates, which results in muscle weakness. That means your payor will consider coding therapy and muscle weakness first be to upcoding.
 
This concept goes beyond the situation in which nursing and PT are being provided. It applies if more than one therapy is being provided, in which case you'd code the condition(s) being treated and then the V codes for therapy.

Essential: Official Coding Guidelines state that if the primary reason for admission is rehabilitation, then the coder should list the appropriate V code for the service, followed by the diagnosis or problem for which the service is being performed. But this guideline does NOT apply to home health coding.
 
You can consider coding the therapy first if that is the only service being provided. However, a better bet would be to code an acute condition being treated as primary over the V code.