OASIS Alert

Consider this scenario: When Mrs. Jones is admitted to home care for physical therapy after a week of bedrest in the hospital, most clinicians wouldn't be surprised to find she is weak and needs more help than she used to. But does this qualify as 728.87 (Muscle weakness) for M0230?

In 2004 home health has two new codes in the 728 category, both case mix codes. Knowing when to apply these codes could affect both accuracy and reimbursement.

728.88 (Rhabdomyolosis) applies to a specific disease causing muscle weakness, and it requires very specific orders from the physician, coding experts say. But 728.87 (Muscle weakness) "will be used considerably within home health," predicts Chapel Hill, NC-based consultant Judy Adams with the LarsonAllen Health Care Group.

A geriatric patient confined to bed for a one-week stay in the hospital can lose 30 percent of her muscle mass, observes consultant Lynda Dilts-Benson with Reingruber & Co. in St. Petersburg, FL. So while she may no longer be experiencing the acute condition that resulted in hospital admission, she may have incredible difficulty with transfer skills, toileting, upper body dressing and overall lack of endurance.

Physicians commonly prescribe physical therapy for these patients, and clinicians need to know whether to use 728.87 (Muscle weakness), 728.2 (Muscle disuse atrophy, not elsewhere classified) or 780.79 (Generalized weakness).

Important point: According to ICD-9-CM coding guidelines, 728.87 (Muscle weakness) excludes 780.79 (Generalized weakness). That means these two codes should not appear together on a patient's list of diagnoses, Benson says.

Physicians requested the new muscle weakness code to have something more specific than 728.9 (unspecified disorder of muscle, ligament or fascia) to define one reason for neurodiagnostic testing, according to Dr. Laura Powers with the American Academy of Neurology.

Clinicians may find themselves using 728.87 in place of 728.2 (Muscle disuse atrophy), Benson predicts. In the coding manual, muscle disuse atrophy is an "other specified code," Benson says. This means while a patient's record may specify the diagnosis, the ICD-9 system "doesn't have a specific code that describes [it]," she says. Because 728.87 is a specific diagnosis under coding guidelines it will be a better choice than 728.2 in many cases, she adds.

TIP: Your choice of codes depends on how the physician describes the condition, stresses Sue Bowman with the American Health Information Management Association in Chicago. If the physician describes the condition as muscle disuse atrophy, use 728.2. "If the patient's condition is described as 'muscle weakness' or 'muscular weakness,' the appropriate code is 728.87," she tells Eli.

However, regional home health intermediary Cahaba GBA warns that 728.2 is not an appropriate code for temporary muscle weakness following a short hospitalization. It should be used when there is measurable muscle atrophy and a specific cause, or a prolonged period of inactivity, and documentation should reflect this, the RHHI instructs in a October 2003 home health update. Otherwise, for generalized loss of strength, 780.79 would be more accurate, Cahaba tells providers.