Long-Term Care Survey Alert

Question: I’ve just relocated to a SNF 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 sure what to fix. Here’s an example of a claim that was denied: A multidisciplinary case was admitted to our facility, where nurses, PTs and OTs cared for a patient experiencing an exacerbation of her multiple sclerosis (MS). The nursing staff adjusted her medication, occupational therapy addressed her increased muscle weakness, and physical therapy assisted her with correcting gait abnormality. The 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?

Answer: Your colleague was right. Your V codes are the problem. In the past, when billing received therapists’ evaluation forms, many coders misused V57.x (Care involving use of rehabilitation procedures) as "procedure codes" to indicate that a patient was receiving therapy, when the V codes were only meant to indicate if therapy was the primary reason for admission.

According to the V-code guidelines for patients receiving therapy in SNFs and home health it all comes down to the question, "What was the primary reason the patient was admitted?" If therapy isn’t the primary reason for admission, you should not even list a therapy V code. In your case, the patient wasn’t admitted specifically for therapy but for her MS exacerbation -- and just happened to have therapy as part of her treatment.

If, however, your facility admits a patient whose only reason for admission is therapy, you should list V57.x -- and you must list it first. For example, a patient is admitted to a SNF after a fracture for physical therapy and occupational therapy.

Watch for: A patient receiving multiple disciplines (e.g., physical therapy and speech-language pathology) could trigger some improper use of V57.89 (Other multiple training or therapy).

Here’s how: If a patient has multiple therapy disciplines involved, your therapists are probably managing exacerbations of a disease process, and if so, the disease process code should replace V57.89. The only time you can report V57.89 is when your therapists are providing more than one discipline for a therapy-only admit.

Tip: You may also want to be alert to Part B therapy cap exceptions claims. Just listing the V code for a therapy-only patient is not enough -- the claim needs to list the qualifying condition and complexities codes as well.