MDS Alert

Published on Fri Sep 04, 2009 PDF

Find out the secret to navigating the murkier scenarios.

Your SNF has admitted a Medicare Part A skilled patient with an active medical condition who is receiving rehab therapy. Should you use rehab as the principal diagnosis?

Short answer: "In my mind,"says Ellen Strunk, PT, MS, GCS, a consultant with Rehab Resources & Consulting Inc., "it all boils down towhat is the reason for the admission to the SNF?"

Key point: "The coding guidelines are very clear that if the reason for admission is rehab, then you put rehab as the principal diagnosis (V57) on the health record and the UB-04 claim form," emphasizes Charlotte Lefert, RHIA, coding strategy facilitator for the LTC Community of Practice for the American Health Information Management Association. "The next code(s) would be the diagnosis that is the reason for the rehab."

The guidelines also say that you use only one code from category V57, Lefert adds. If the SNF is providing more than one type of therapy services, use code V57.89, indicating multiple therapies, Lefert counsels.

Comorbidities usually impact the person's length, duration and progress in therapy -- and they go to show why the person needs to receive rehab as an inpatient rather than an outpatient, says Ron Orth,RN, NHA, CPC, RAC-MT, president of Clinical Reimbursement Solutions LLC in Milwaukee. A lot of times, however, "the principal reason the person with comorbidities is coming to the SNF is still therapy services," Orth adds.

Just because the person is getting rehab, however, doesn't mean the rehab diagnosis should always "trump other conditions the patient is being treated for," says Strunk.

Suppose someone had abdominal surgery and wound dehiscence, and the person is primarily coming to the SNF for wound care but is getting some rehab therapy, Orth proposes.

Key strategy: In such cases, the nursing home's team should consider the team's focus and intensity of care for the resident.

As an example of how that decision-making would work, Lefert poses a scenario where a patient has an MRSA infection due to a hip prosthesis. The surgeon cleaned out the infection, but the resident will continue on antibiotics and has some therapy ordered (PT/OT).

The decision whether nursing or therapy is getting the most focus will differ based on whether the person is really sick with MRSA -- and that's the primary focus of care --or if he's just getting IV antibiotics once a day and is strong enough to participate in therapy with a goal of main- taining his functional status in order to go home, says Lefert. If the team determines rehab therapy is the primary focus for the patient, then you'd put V57.89 first, followed by 996.66 for the infection, which is a complication from the hip prosthesis, says Lefert. Next, you'd put 041.12 for the MRSA infection, she adds.

On the other hand, "if nursing is the focus and you have a principal diagnosis related to the nursing care (996.66), then you would not put  V57 on the record," instructs Lefert.A code from V57 codes can only be a first-listed diagnosis, she adds.

Either way: In both of the afore-mentioned scenarios, you should list and code other conditions being treated or having a functional impact on the resident's progress in therapy (e.g., COPD, congestive heart failure, severe arthritis, etc.), Lefert says. (For another coding example provided by Lefert, see page 113.)

The principal diagnosis (FL67) on the UB-04 "should be the reason that is responsible for the service being provided as shown in the medical record," says Marilyn Mines, RN, RAC-CT, BC, manager of clinical services for FR&R Healthcare Services in Deerfield, Ill.

The bottom line: Diagnoses are important to support the medical necessity of the services being provided, says Orth.

"But in a medical review situation,it's going to be the documentation in the clinical record to support whether the [therapy and nursing services] were reasonable and medically necessary [and required the SNF level of care]," Orth adds.