As I sit and think of what to write about in this article, symptom codes come to mind. There are still lots of discussion on whether to use 781.2 abnormality of gait, 728.87 muscle weakness, or 780.79, malaise and fatigue. If you know what diagnosis is causing these symptoms, or for any other symptom codes, if it's integral to the diagnosis, then you do not use these codes unless you are instructed to by the official coding guideline.
Below are some examples:
• Patient admitted to hospital with pain in hip after fall. The patient had a fractured hip. Treatment was total hip replacement. Skilled nursing will be seeing patient for incision care and watching for any signs of infection. Physical therapy will be seeing patient for abnormality of gait and muscle weakness.
V58.41 Aftercare following joint replacement
820.8 Fracture of hip goes in MO246
V43.64 Hip replacement
E888.9 Falls NOS
There is no need to code 781.2, abnormality of gait, or 728.87, muscle weakness, because these symptoms are integral to hip fracture.
• Patient referred to home health agency due to recent fall with fracture of ankle. Had open reduction with internal fixation device and discharged to home health. Physical therapy and skilled nursing services involved in patient's care.
V54.16 Aftercare for healing traumatic fracture of lower leg
824.8 Ankle fracture goes in MO246
E888.9 Falls NOS
The aftercare code covers both the physical therapist and the skilled nursing services. No need to code muscle weakness as it is integral to the ankle fracture.
• Patient is admitted with history of falls with unknown etiology. This is physical therapy only case. Referral received form physician for abnormality of gait and check for safety in home.
V57.1 Other physical therapy
781.2 Abnormality of gait
This is coded as V57.1 because that is the only service involved in this episode of care. You can code the abnormality of gait because it is unknown why patient is experiencing falls in home.
• Patient was admitted to hospital with CVA. Patient has muscle weakness from the CVA. Patient referred to home health for continuing monitoring of CVA and muscle strengthening.
438.89 Other late effects of cerebrovascular disease
728.87 Muscle weakness
The acute stage of the CVA is addressed in the hospital. Home health covers late effects of CVA. The Decision Health Coding Book has a coding tip that instructs you to code 438.89, Late effects CVA, followed by 728.87, muscle weakness. This is one exception that you do show the symptom even though it is integral to the diagnosis. It helps explain what is being addressed in the plan of care.
• Patient with exacerbation of multiple sclerosis is having problems with abnormality of gait. The home health agency has received a referral from physician for SN for management of multiple sclerosis and assessment of medications changes physician has made. Physical therapy is referred to assist patient with abnormality of gait.
340 Multiple Sclerosis
781.2 Abnormality of gait
Abnormality of gait is not integral to multiple sclerosis. In this instance, you can code multiple sclerosis as the primary diagnosis because the agency is seeing patient for more than one aspect of the disease.
Just a reminder that new ICD-9 code changes are coming Oct. 1. A list of the code changes can be found at http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#
You should familiarize yourself with these changes before the Oct. 1 date arrives. If you have the opportunity to take advantage of a teleconference regarding these changes, that would be advantageous also. Keep connected to the listserv to stay on top of discussion regarding these changes and other topics of discussions. The listserv has a great group of people helping one another in their coding challenges. You can find this listserv and others at www.homehealthinteractive.com.
Another part of home health coding is the OASIS assessment required from Medicare. This is where the clinician documents the data when admitting a patient to home health services. The OASIS items are integrated into the patient assessment. The coder must read the OASIS assessment, along with other documents available to ensure the documentation supports what is being coded and also to be able to be more specific in the diagnosis coding. I have just recently received the certification for OASIS Specialist-Clinical sponsored by the OASIS Certificate and Competency Board. You have to complete a 100 item, 2.5 hour exam. I attended an 8-hour workshop the day before I took the exam. It is an open book exam. I received a binder full of information regarding OASIS the day of the workshop. I took this binder with me the day of the exam. I've been working with OASIS for many years, first in data entry as the clinicians filled out the paper form of OASIS. Then continued working with the OASIS as the clinicians started entering the information into laptops.
I can now help clinicians in their documentation in answering these OASIS questions correctly. I believe the coding and the OASIS document go hand in hand in home health coding. As in coding, there is a listserv for OASIS also. I stay connected to both listservs. There will changes in the OASIS assessment coming in the New Year. It will be changing to OASIS-C. There are workshops scheduled in the fall to attend to be on top of the changes that will be coming Jan. 1, 2010. To find more information regarding OASIS certification, you can log onto www.oasiscertificate.org.
Jen Noel has worked in the home health industry for more than 16 years with the Visiting Nurse Association of Hanover and Spring Grove, learning many aspects of home health and completing many job responsibilities. She started learning coding approximately 4 years ago through a co-worker, workshops and becoming a member of a coding forum. She became a certified home health coding specialist - diagnosis (HCS-D) on Nov. 1, 2007 and is now working for Parente Randolph as a consultant in addition to her work with the Visiting Nurse Association of Hanover & Spring Grove on a PRN basis.