Part B Insider (Multispecialty) Coding Alert

Published on Fri Oct 22, 2010 PDF

Question: How do we know which ICD-9 code to list for generalized weakness in the Medicare population? Our clinicians have been listing 728.87 for patients recovering from strokes, the flu, or bouts of pneumonia. But I have heard that you need to show muscle atrophy measurements when you report this code. How do we code for these patients?

Answer: According to the American Hospital Association's quarterly Coding Clinic, code 728.87 should be used to report the "unique" condition of muscle weakness. You can use 728.87 (Muscle weakness [generalized]) to report deconditioning or a general decrease in muscle strength but be sure your plan of care includes documentation of a manual muscle test indicating the patient isn't of normal strength.

Don't get tripped up by the non-essential modifier "generalized" in the descriptor for 728.87. You should use 728.87 to report generalized muscle weakness, not generalized weakness. The word "generalized" was added to clarify that the code can be used for generalized muscle weakness; not just weakness of one muscle group.

For patients with long-term weakness -- not weakness after a brief hospital stay -- you can list 728.2 (Muscular wasting and disuse atrophy). But make sure your documentation shows a measurable decrease in the size of muscle groups or a prolonged period of inactivity.

For example: If your physical therapist does circumferential measurement of the patient's limbs, the measurements should show that one limb is a lot weaker or smaller than the other. To report weakness, lack of strength, loss of energy, lethargy, listlessness -- the type of weakness that may follow viral infection, use 780.79 (Other malaise and fatigue). These patients don't require therapy to address their weakness, they just need some time to recover and get their strength back.

If you are caring for a frail, infirm, feeble, or weak patient, 799.3 (Debility, unspecified) may be the right code. List 799.3 after the condition that causes the debility.