OASIS Alert

Document testing if you want to get paid.

Question: We recently admitted an elderly patient for physical therapy following a flu episode that left her with increased weakness. The OASIS assessment and PT evaluation indicated that the patient had general weakness, but didn't document any strength measurements. The primary diagnosis in M0230 was 780.79 (Other malaise and fatigue). The PT provided two visits a week for five weeks for gait training and therapeutic exercise. After five weeks, the patient showed no appreciable improvement and the claim was denied as not medically reasonable and necessary. How should we have coded this differently for this patient?

Answer: This does not appear to be a coding problem, answers physical therapist Rick Gawenda, director of physical medicine and rehabilitation for Detroit Receiving Hospital and owner of Gawenda Seminars. Although you probably should have used ICD-9 code 719.7 (Difficulty in walking) in M0230, as the primary diagnosis for this therapy-only episode, because the patient did receive gait training.

The real problem is that this patient showed no rehabilitation potential. A patient with malaise and fatigue usually gets better with a little assistance or rest -- or just doesn't get any better. Documented strength measurements (a beginning strength and an ending strength) and a complete objective report of the patient's gait may have helped you get reimbursement, because you needed to show the patient's improvement.

In addition, documented balance tests, such as Tinetti, Berg, Get Up and Go test, or the Functional Reach test could have supported the need for therapy services due to static and dynamic balance deficits during gait and/or performance of activities of daily living in the standing position. Without demonstrated progress, the care doesn't seem medically necessary and providing 10 visits was probably excessive. A home exercise program and a few visits would possibly have been allowed, or at least kept you out of the therapy edit.

Bottom line: Documentation is what gets you paid. No matter what you have coded, you need the documentation to support the services you provide.