OASIS Alert

Without the correct words, the coder is left in the lurch.

Whether your clinicians do their own coding or your agency uses a coding expert, the words therapists and nurses use in the medical record will be compared with the diagnosis codes in M0230 and M0240. If they don't match, you're looking at financial losses and even fraud charges.

Pitfall: It's easy to think of coding as a separate realm presided over by people who like dealing with detail and numbers. But clinicians and coders alike need to remember that responsibility for determining the primary and secondary diagnoses rests on the assessing clinician -- in collaboration with the physician, experts say.

Coders may supply the numbers, but clinicians must supply the words, said coding and OASIS consultant Sparkle Sparks with Redmond, WA-based OASIS Answers. The coders choice of diagnoses is driven by the clinician's choice of words to describe the patient's primary and secondary medical conditions and functional abilities, Sparks told a packed session at the October annual conference of the National Association for Home Care & Hospice held in Denver.

Example #1: ICD-9 code 728.87 (Muscle weakness) was added to the list in 2003 at the request of neurologists to "describe weakness of unknown etiology or deconditioning," Sparks said. If you choose to use this code, you should have manual muscle testing that shows weakness, she said (for a chart showing questions to ask yourself before using this code, go to p. 106). You also should set functional goals to measure the impact of your program and provide therapeutic exercises and a home exercise program.

Example #2: On the other hand, if you decide to code 719.7 (Difficulty in walking), you need to know that this code is in the Musculoskeletal System and Connective Tissue chapter of the coding manual under the category 719 (Other and unspecified disorders of the joint), Sparks explained. You are looking for language in the chart that relates the patient's ambulation problems to lower extremity joint problems that have not been surgically treated, she said.

Documentation must paint a professional picture of the patient, Sparks said. It also has to include the components that support medical necessity.

Don't: The assessment can't just be a description of the distance a patient can walk, what assistive device she is using and how much assistance she needs, Sparks emphasized. Anyone can do that.

Do: Instead, use clinical terminology, describe the components of the deficit and record the corrective intervention needed, she said. Although coding practices may draw an intermediary's attention, what sinks or saves the claim is the documentation.

Bottom line: Regional home health intermediary Palmetto GBA includes in its local coverage determination more than 530 ICD-9 codes that support the medical necessity of physical therapy in the home, Sparks reminded providers. Clinicians need to describe the patient in terms that help coders know which code applies. Use the "popular" therapy diagnoses correctly and don't limit yourself to these few favorites, she said.

Note: More information on therapy coding is in the CD or MP3 download of Sparks' presentation: "I Made the Visit -- What Else Do You Expect" available through http://www.nahc.org.