Should You Follow Coding Guidelines Or Examples?
If you struggle to decide whether to use ICD-9 code 781.2 (abnormality of gait) or 719.75 (difficulty with ambulation) in your diagnosis coding, you're not alone - and guidance is months away. Going strictly by ICD-9 coding guidelines, "abnormality of gait" is used for neurological problems and "difficulty with ambulation" is used for orthopedic problems, explains consultant Linda Krulish with Redmond, WA-based Home Therapy Services. Some situations are clear. Abnormality of gait would be used for situations where an underlying neurological disease - such as Parkinson's - causes the abnormality of gait, but the sole reason you're providing home care is for gait training, says coding expert Prinny Rose Abraham with HIQM Consulting in Minneapolis. This avoids coding a condition that doesn't currenty apply to the patient. But if you are treating multiple manifestations of Parkinson's, then you would code the underlying disease as primary, she adds. Other scenarios are fuzzier. In addition to following coding rules, home health coders look to examples provided by the Centers for Medicare & Medicaid Services for clarity, and there is some conflict between the two, experts agree. A common confusing situation is a patient admitted to home care for gait training following the repair of a hip fracture or a total hip replacement. The primary reason for home care is for physical therapy. Since the underlying condition resulting in ambulation problems is orthopedic, coding guidelines would seem to indicate using 719.75 as the diagnosis code. But CMS repeatedly provides examples that suggest using 781.2 instead. In the new case examples CMS released Sept. 30 to demonstrate the use of V codes, one scenario involves a patient admitted to home care with doctor's orders for PT for gait training, following surgical repair of a hip fracture. CMS lists the "diagnosis reporting requirements" as M0230 (a) V57.1 (physical therapy); M0240 (b) 781.2 (abnormality of gait); M0240 (c) V54.13 (aftercare for healing traumatic fracture of hip) and M0245 (a) 781.2 (abnormality of gait). In the discussion, CMS states 781.2 was chosen as the first secondary diagnosis "because it accurately describes this patient's current condition and her need for therapy ... and because the physician specified gait training." Agencies' concern is that 781.2 is a case mix diagnosis while 719.75 is not, Krulish explains, leading to the question: Do you follow coding guidelines and get less reimbursement or follow CMS' instructions and get more reimbursement? Some agencies take the conservative route and follow only the coding guidelines. Others point to the fact that CMS repeatedly illustrates the exact scenario they're involved in, so they follow the answers CMS has provided. A question recently posted to regional home health intermediary United Government Services' Web site considers the case of a patient admitted for PT only following a total hip replacement for degenerative joint disease. "Based on the coding information UGS has, we would agree that ICD-9 code 719.75 would be the most appropriate code to use. This conclusion is based upon the fact that codes from 719 are to be used only if a joint disorder is involved," the RHHI states. Many coding decisions involve shades of gray, Abraham suggests, and "if you put five coders in a room you'll get five different answers to the same scenario." Abraham uses CMS examples in her coding seminars and acknowledges the confusion some answers have caused. But a clarification is in the works, Abraham told listeners in her Nov. 20 teleconference "2004 ICD-9 Coding Update for Home Health Agencies," sponsored by Eli. "Look for guidance in the first quarter of 2004, in the American Hospital Association's Coding Clinic," she counseled. Editor's Note: The UGS questions and answers are at www.homecarenj.org/public/UGSHomeHealthAdvisoryQA03.doc. The CMS examples are at www.cms.hhs.gov/providers/hhapps/diagnosis.pdf.
