Home Health ICD-9/ICD-10 Alert

Published on Sun May 06, 2007 PDF

Nix V57.x when multiple disciplines provide multiple aspects of care

You already know that you should reserve V57.x codes (Care involving use of rehabilitation procedures) for primary diagnoses, but are you sure you're not reporting these codes too frequently?

Medical review activities show home care agencies are still reporting V57.x codes too often, the Centers for Medicare & Medicaid Services cautioned in its proposed rule on prospective payment system changes released April 27.

Come audit me: Overusing V57.x codes raises a red flag for regional home health intermediaries (RHHIs) to scrutinize your claims, says Jun Mapili, PT, MAEd, rehab therapies supervisor with Global Home Care in Troy, MI. If your agency's use of V57.x is above the national or state average, your claims are susceptible, he says.

To help keep your V57.x use in check and your claims secure, Mapili offers three crucial tips:

1. Don't list a V57.x code when therapy is an incidental service.

Use a V57.x code for "admissions for therapy" or "encounter for rehabilitation," Mapili says. Don't use these codes when the therapy is an "incidental treatment" and the patient was admitted for another reason.

Example: Your patient was admitted to home care due to an acute exacerbation of myasthenia gravis. Nursing will provide observation and assessment and teaching for new medications; physical therapy will provide progressive muscle strengthening and activities of daily living (ADL) training; and a home health aide will assist the patient with ADLs and personal care.

Although muscle weakness is the most predominant symptom of myasthenia gravis, you would not report V57.1 (0ther physical therapy) in M0230a, Mapili says. The reason for this patient's admission is more than just muscle weakness--it's an acute exacerbation of myasthenia gravis (358.01). The rehabilitation in this situation is an incidental service, he says.

Hidden bonus: Listing 358.01 in M0230a will earn your agency 20 case mix points.

2. Don't list V57.x if therapy isn't the most intensive service.

Suppose your patient has had an acute exacerbation of chronic obstructive pulmonary disease (COPD) and is experiencing generalized weakness, body malaise and fatigue. He lives alone and has a history of above-knee amputation. Nursing will visit once a week for five weeks, physical therapy will visit twice a week for four weeks, and the home health aide will visit three times a week for five weeks.

Error magnet: Some coders would argue that you should report V57.1 in this scenario because the number of visits for therapy is higher than that for nursing. This is an incorrect assumption, Mapili says.

The patient's body malaise and fatigue are symptoms of COPD. The acute exacerbation of COPD requires the most intensive service, Mapili says. COPD is also the most acute condition--not the body malaise and fatigue. Even if the patient exhibits a true muscle weakness (728.87), the COPD is still the most acute condition in this case and would definitely trump any V code.

For this patient, report the following codes, Mapili suggests:

• M0230a: 491.21 (Obstructive chronic bronchitis; with [acute] exacerbation);

• M0240b: 780.79 (Other malaise and fatigue); and

• M0240c: V49.76 (Lower limb amputation status; above knee).

No Clear Answers For Multiple Disciplines With Therapy Primary

Gray area: Multi-disciplinary cases can pose a coding challenge. When each discipline is going to the home for different reasons but therapy is primary, many coders are tempted to list a V57.x code on M0230a, says Trish Twombly, RN, BSN, HCS-D, director of coding with Foundation Management Services in Denton, TX.

For example: Muscle weakness is the primary reason for home care, but the patient also requires intervention for diabetes. Therapy will address the patient's muscle weakness while nursing will provide diabetic teaching. In this case, if the therapy is primary, the temptation is to code as follows:

• M0230a: V57.1 (Other physical therapy);

• M0240b: 728.87 (Muscle weakness [generalized]);

• M0240c: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled); and

• M0240d: V58.67 (Long-term [current] use of insulin).

However, other coders concerned about using V57.x codes too frequently and arousing their RHHI's interest would instead report:

• M0230a: 728.87 (Muscle weakness [generalized]);

• M0240b: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled).

Which is the right way to go? "It's a gray area," Twombly says. Until home health coders receive more specific instructions from CMS or an update of the coding guidelines, there's no real clear-cut answer.

Stay tuned: CMS's concerns about overuse of the V57.x series are evident in its proposed changes to PPS. Clarification could be coming, experts predict.  

3. Don't report V57.x codes if multiple disciplines are addressing multiple aspects of care. 

In a multi-disciplinary approach, your agency will provide multiple aspects of care. Otherwise you could be looking at possible denials due to duplication of services.

Example: Your patient received a joint replacement to repair a hip fracture. The nurse will visit two to three times for staple removal and teaching related to the joint replacement. The physical therapist will provide gait training for 16 visits.

Don't list V57.1 for this patient, Mapili says. The patient was admitted for both rehabilitation and skilled nursing (multiple aspects of care), so V54.81 (Aftercare following joint replacement) is your primary diagnosis, he says.

Follow this with 781.2 (Abnormality of gait), the V43.6x code to indicate the affected joint and V58.32 (Encounter for removal of staples).

Final step: And don't forget to put 820.8 (Fracture of neck of femur; unspecified part of neck of femur, closed) in M0245. The aftercare V code in M0230a replaces the hip fracture code in this scenario, so you're able to list the fracture code in M0245 for 11 case mix points.

Note: Watch upcoming issues of Eli's Home Health ICD-9 Alert for the latest word on how and when to use V57.x.