Eli's Rehab Report

Question: Our new home health patient is receiving physical therapy only following an acute CVA with hemiplegia of his dominant side. He also has hypertension, diabetes and is clinically depressed. Physical therapy will see him for gait, transfer, balance training, assistance with adaptive equipment, home safety and to teach a home exercise program.

The therapist will also monitor his hypertension, diabetes and clinical depression by evaluating the effect of the exercise program on the blood pressure, evaluating for any changes in diabetes due to the change in activity and watching for a lack of participation and motivation to follow through with the home exercises program and participate in therapy due to depression. How should we code for this patient?

Answer: List the following codes for this patient, says Judy Adams, RN, BSN, HCS-D, HCS-O, COS-C, with Adams Home Care Consulting in Chapel Hill, N.C.

• M1020a: V57.1 (Other physical therapy);
• M1022b: 438.21 (Late effects of cerebrovascular disease; hemiplegia affecting dominant side);
• M1022c: 401.9 (Essential hypertension, unspecified);
• M1022d: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled); and
• M1022e: 311 (Depressive disorder, not elsewhere classified).

Because this is a therapy-only case, you'll list V57.1 as the primary diagnosis. Follow that with 438.21 to indicate that you are treating hemiplegia as the late effect of a CVA. This particular late effect has a combination code so you don't need to run down the usual late-effects sequencing guidelines and exceptions to code for this patient.

Next, list 401.9 to indicate that your patient has hypertension since this is a comorbidity that can impact or be impacted by the therapy services. The therapist will be monitoring blood pressure readings on her visits and reporting any changes, if applicable, to the physician based on either agency-specific parameters or parameters determined by the patient's physician as part of best practice standards.

Although 401.9 is no longer a case mix code, it's still important to report when applicable to a patient's condition. The biggest mistake home health agencies can make in response to the hypertension case mix changes is to stop reporting 401.9 and 401.1 (Benign essential hypertension) when they have the potential for impacting the home health plan of care and are being monitored and evaluated as part of the plan of care, now that they no longer earn case mix points, Adams says. "That would be saying to CMS, 'Home Health really does code based on reimbursement,'" she says.

Follow this with 250.00 for your patient's diabetes. He doesn't have any manifestations, but the therapist is monitoring this condition and watching for any changes that may occur due to his other health issues and their treatment.

Finally, list 311 to indicate that your patient has depression. The therapist is monitoring the depression and watching for its impact on the patient's follow-through with the home exercise program and therapy participation, so it's appropriate to include this diagnosis. Documenting any coordination of care with the patient's mental health provider is important.