Home Health ICD-9/ICD-10 Alert
Determine The Cause Before Coding Weakness
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Question: How should I report the following scenario: The patient was hospitalized for a urinary tract infection (UTI). It is now resolved, but the illness has left him weak and unable to ambulate as he did prior to his illness. We are providing physical therapy three times a week. Should I list V57.1 for physical therapy, 799.3 for debility and 719.7 for difficulty walking? -- Kentucky Subscriber Answer: If you're admitting the patient for therapy and the acute condition is resolved, then V57.1 (Other physical therapy) is appropriate for the primary diagnosis. Debility means the patient is frail and weak and is usually coded after the conditions causing the patient's debility. Difficulty walking is reserved for those gait issues resulting from a chronic condition of the bone or joint. If the patient was hospitalized for a urinary tract infection and has so much weakness, it may have been septicemia. At times during a UTI, the patient becomes dehydrated and that is what causes the continuing problem with weakness. Even if those conditions are resolved now, the patient can be left with deconditioning. Deconditioning is coded 728.87 (Muscle weakness [generalized]). Before choosing vague diagnoses such as deconditioning for the patient's care, ensure that there is not another more definitive diagnosis.
Home Health ICD-9/ICD-10 Alert
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