Home Health ICD-9/ICD-10 Alert

Published on Sat Nov 11, 2006 PDF

Secure maximum reimbursement when your care focuses on multiple aspects of an underlying disease.

Learning when to report 728.87 for muscle weakness or 728.2 for muscle wasting will help boost your reimbursement as well as your coding accuracy.

Reserve 728.2 For Measurable Atrophy

Use code 728.2 (Muscular wasting and disuse atrophy, not elsewhere classified) when documentation shows a measurable decrease in the size of the muscle groups, says Lucie Carter Lopez, RN, BA, HCS-D, clinical supervisor with Interim Health Care in Fresno, CA. "I'd stay away from 728.2 unless you actually have muscle measurements to document, and that doesn't happen really often," she says. 

Red flag: Payers expect the decrease of the muscle groups to be documented, and you can expect downcoding if you don't have a record of these measurements.

Report 728.87 For Muscle Strengthening

Report 728.87 (Muscle weakness [generalized]) as primary when progressive muscle strengthening is the focus of care, says Jun Mapili, PT, MAEd, rehab therapies supervisor with Global Home Care in Troy, MI. For therapy-only cases with a focus on muscle strengthening, list 728.87 as the first secondary diagnosis following V57.1 (Other physical therapy), he says. You should also list 728.87 in M0245a as the payment diagnosis in this therapy-only scenario.

Identify the proximate condition: Although muscle weakness can be considered a symptom of another condition, the code 728.87 was added in 2003 to describe the "unique condition" of muscle weakness.However, some intermediaries consider muscle weakness a symptom or sign of another condition. So you should make your code selection based on the proximate-condition-versus-the-underlying-condition concept. Using this guideline, avoid coding a long-term chronic condition first when the focus of the care (the proximate reason) is muscle weakness.

You'll typically report muscle weakness for patients with neurological diseases such as Parkinson's disease, amyotrophic lateral sclerosis (Lou Gehrig's disease), multiple sclerosis, myasthenia gravis, and Alzheimer's disease, Mapili says. However, you can also use muscle weakness to describe the residual effect of orthopedic conditions such as fractures, hip joint replacement (arthroplasty), and amputation.

Know When To Report The Underlying Diagnosis

Knowing when to code for the condition that causes the muscle weakness ensures that your agency gets all the reimbursement it deserves for these complex patients. Neurological cases garner more money in the clinical domain of the OASIS, earning 20 points as compared to 11 points for muscle weakness, Mapili points out. 

Tip: The key to coding correctly is to look at the aspects of care being addressed, Mapili says. 

If the therapist is addressing multiple aspects of care, you can report the underlying diagnosis (such as myasthenia gravis) as primary rather than the proximate diagnosis (muscle weakness), Mapili says. 

For example: In a therapy-only case, the therapist is addressing the disease process, functional training and progressive muscle strengthening. This would be considered multiple aspects of care, Mapili says. However, if the therapist's only focus of care is progressive muscle strengthening, you should code for the muscle weakness first.

Don't Shy Away From 728.87

Some coders have been reluctant to use 728.87 because they've been applying the more exacting 728.2 guidelines to this generalized code as well, Lopez says. If your patient has been in the hospital for a while and you anticipate that he is going to get this muscle function back, you're not supposed to use 728.87, she says. But if you have documentation and can show that the patient would not get back his muscle function without physical therapy, then you shouldn't worry about using 728.87.

Coding example: You have been providing aftercare for a patient who is recovering from a hip fracture. She develops pneumonia and returns to the hospital. When she comes home from the hospital, she is in worse shape than she was after the hip fracture. Because the pneumonia occurred so soon after the post-fracture period, this patient is unlikely to regain her muscle strength without physical therapy, Lopez says. So, coding 728.87 is appropriate.

Avoid 728.87 Denials And Downcoding

You can report 728.87 for the condition of muscle weakness, especially when the weakness is below the functional grade (3+/5 for upper extremity and 4/5 for the lower extremity), Mapili says. However, before you assign the code for muscle weakness, you should consider more than just a muscle grade, he says. Documentation that supports the use of this diagnosis code includes:

• A detailed history of muscle weakness and how it was developed, including the contributing factors. For example, "Patient had history of muscle strain on the elbow where the patient did not move the specific body part for a prolonged period of time (two months). Pain that was previously managed through medication is gone, but muscle weakness is very evident at present and it is the focus of care."

• A description of the functional implication of muscle weakness. For example, "Unable to do upper extremity activities independently. Needs 25 percent human assistance in grooming, and upper and lower extremity dressing. Needs moderate assist in transfer."

Red flag: The functional domain of the OASIS must reflect the muscle weakness implication to validate the use of the code 728.87, Mapili says. For instance, a functional status score of F0 or F1 doesn't support a muscle weakness diagnosis.

• An indication of the prior level of function. Documentation should describe what the patient could and couldn't do prior to the onset of muscle weakness.