Home Health ICD-9/ICD-10 Alert

Code 728.87 is a five-digit code that was added to ICD-9-CM in 2004, Mihalik says.

Make an Accurate Determination

You want your codes to be as accurate as possible, Mihalik says, and that's a tough task without more guidelines for using these codes.

Determine your muscle weakness codes based on how the medical record describes the patient's condition, says Sharon Sandberg, CPC, home health coder with Condell Home Health in Libertyville, Ill. "I use a lot of different criteria to choose the right code, and I base my determination primarily on what the clinician believes the patient's condition to be. I accomplish this by explaining the differences in the codes to the clinicians," she says.

Muscle disuse atrophy: If the medical record indicates muscle disuse atrophy with a specific cause or a prolonged period of inactivity, you should report 728.2. Code 728.2 is also appropriate for a patient who has been in the hospital for a long time, has not had any therapy and comes home bedridden, has a problem sitting and standing, and requires standby assistance, Sandberg says. Tip: To code this, you must have a measurement validating the loss of muscle mass, says Lynda Dilts-Benson, RN, CAM, CORN, HAS-DO, HARM, a consultant with Reingruber and Co. in St. Petersburg, Fla.

Muscle weakness: Code 728.87 is general enough that home health coders will be using it fairly often. Before 728.87 came along, most HHAs had to report 728.9 (Unspecified disorder of muscle, ligament, fascia), even though coders prefer not to use unspecified codes, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver. Muscle weakness is a fairly common diagnosis in geriatric populations and postsurgical rehabilitation patients, so 728.87 was a welcome, more-specific addition in 2004.

You might also use 728.87 when you formerly reported 780.79, Hammer says. "Reporting 780.79 definitely was not a great fit when treating generalized muscle weakness." If the medical record states "muscle weakness" or "muscular weakness," you should report 728.87.

Tip: According to ICD-9 coding guidelines, code 728.87 excludes 780.79, which means you should never report both codes on a patient's list of diagnoses.

Generalized weakness: Report 780.79 when a patient has generalized weakness, not atrophy or documented muscular weakness. Look for terms such as "tiredness," "loss of energy," "fatigue" and "exhaustion."

Avoid This Coding Pitfall

One trap you don't want to fall into is reporting a muscle weakness or generalized weakness code when you  should actually report 781.2 (Abnormality of gait). If a patient is generally weak and a therapist is visiting the patient to work on gait, you should report 781.2 instead of 780.79, Sandberg says. Whenever the main focus of the therapy is gait training and balance, Sandberg recommends reporting 781.2 as the diagnosis code. "If the therapy focuses on an exercise program, balance and transfers, and not assisting the patient to walk, then I would choose the generalized weakness code," she says.

Bottom line: "I don't have a standard protocol that I go by for every patient because each patient's case is different," Sandberg says, "so I determine the correct code based on the clinician's answers to the questions I ask."