Eli's Rehab Report

Question: An elderly patient who recently had a flu episode was referred to our home health agency for physical therapy because of increased weakness. The evaluation indicated that the patient had general weakness but didn't document any strength measurements. The agency reported 780.79 (Other malaise and fatigue) as the primary diagnosis, and the therapist provided two visits a week for five weeks for gait training and therapeutic exercise. After five weeks, the patient showed no indication of any appreciable progress, and our payer denied the claim as not medically reasonable and necessary. Should we have coded differently for this patient?

Answer: This doesn't appear to be a coding problem. But you should have used ICD-9 code 719.7 (Difficulty inwalking) because the patient did receive gait training, and this may have been the primary code for therapy purposes. Regardless, the patient showed no rehab potential. A patient with malaise and fatigue usually gets better with a little assistance or rest--or he just doesn't get any better.

Documented strength measurements (a beginning strength and an ending strength) as well as 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 progress, the care doesn't seem medically necessary, and providing 10 visits was probably excessive. A home exercise program and a few visits would have possibly been paid, or at least kept you out of the therapy edit.

Lesson learned: Remember, the documentation gets you paid in the end. No matter what you have coded, your documentation is the key.