Medicare Compliance & Reimbursement

Choosing the wrong diagnosis can lead to big problems.

If outpatient therapy providers are treating patients for the effects of a stroke and are using the stroke itself as the treatment diagnosis code, they're making a big mistake.
 
Often when a patient has a cardiovascular accident and is treated for the CVA in the hospital, he needs outpatient physical therapy to treat the physical effects of the stroke. But therapists are choosing the wrong primary diagnosis when they code their therapy.

"If that patient is an outpatient, then CVA is not the best diagnosis to use, because that is not what we are treating," said consultant Sandra Soerries, speaking at a recent teleconference sponsored by The Coding Institute titled "Advanced Coding Strategies for Physical Medicine and Rehab Services." Key idea: A physical therapist is not treating the actual CVA, notes consultant Quin Buechner with ProActive Consulting in Cumberland, WI. Instead, PTs are treating the effects of the stroke, "and should code what they treat," he reminds therapists.

That means therapists should use the CVA as their medical diagnosis, but use the specific reason they're seeing the patient as the primary treatment diagnosis, says Rick Gawenda, director of rehab services at Detroit Receiving Hospital in Detroit.

The rationale: "They're not coming to you for the stroke -- that's what they went into the acute care hospital for. They're coming to you for the gait difficulty," Gawenda explains. It's just like using V codes for aftercare for joint replacement as your primary code, instead of using the code for osteoarthritis of the knee, he says. Outpatient providers should stay away from code 436 (acute, but ill-defined, cerebrovascular disease) altogether, says consultant Patricia Trela with Deloitte & Touche in Boston. "You never put a code for the acute condition unless the condition has never been treated and it's still acute," she explains. Exception: The rules are different for inpatient providers, Trela says. Inpatient rehab facilities should use the acute CVA code, but also cite the date the stroke occurred, she instructs. "There is no coding rationale for this," says consultant Ann Lambert Kremer with Baker Newman & Noyes in Portland, ME. "It is strictly what the payers like."