Home Health ICD-9/ICD-10 Alert

Question: I've just re-located to a home care setting from a hospital outpatient therapy department and am having trouble getting our therapy claims paid. Some of my colleagues have suggested that the problem could be with therapy V codes. But I'm not quite sure what to fix. Here's an example of a claim that was denied: Nurses, PTs, and OTs cared for a patient experiencing an exacerbation of her multiple sclerosis (MS). The nursing staff adjusted the patient's medication, occupational therapy addressed her increased muscle weakness, and physical therapy assisted her with correcting gait abnormality. The ICD-9 codes on the claim form follow: 340 (Multiple sclerosis), V57.21 (Encounter for occupational therapy), 728.87 (Muscle weakness [generalized]), V57.1 (Other physical therapy), and 781.2 (Abnormality of gait). Am I missing something here, or should I appeal?

New York Subscriber

Answer: You could be in a medical review edit because of your sequencing of the V57.x codes. You should only list V57.x codes as primary diagnoses. And in your case because nursing is involved in the plan of care, you shouldn't use the V57.x codes at all. You should only report a V57.x code when the reason for admission is rehabilitation.

If nursing was not involved in the plan of care, you could list V57.89 (Multiple training or therapy) as primary to indicate that the patient was admitted for multiple therapies. But because you are providing multiple aspects of care, you should sequence the MS as primary.

Note: Muscle weakness is an unnecessary code in this scenario because it is integral to MS.