1 This tool is designed to assist the Physical Therapist in consultation with the physician, in the selection of an appropriate according to Medicare coverage guidelines. The documentation tips will add extra support in the record for the diagnoses and help to prevent down coding or denials. Medical Review by the Intermediary will focus on medical necessity and skilled services provided on each visit. ICD- 9 Code Diagnosis Rationale Documentation Tips 780.79 Generalized Weakness Appropriate for a patient that is weak with loss of strength and energy following an illness or hospitalization with loss of function or mobility. 799.3 Debility A general non-specific that is appropriate to use for someone that is frail and weak due to old age and feebleness when establishing a home exercise program with only limited number of visits covered. 728.2 Muscle Wasting and Disuse Atrophy NEC Only used when therapy is concentrating on specific muscle groups that have atrophied. For example hamstring muscles that have atrophied as a result of being immobilized in a cast. Appropriate when the physician indicates amyotrophia NOS or myofibrosis and the treatment of these conditions is the main focus of the POC. Not an appropriate to use for a patient that has muscle atrophy due to the aging process, poor nutrition and decrease in activity. PT evaluation should include the patient s specific level of function and physical limitations that require skilled therapy services. Medicare will not pay for services to restore strength and endurance the patient may have regained on their own post hospitalization. PT evaluation should include the patient s specific decreased level of function and physical limitations. The home exercise program should be designed to return patient to the maximum level of function. Include in the documentation the patient s ability to follow through with a return demonstration of the exercise program. Document the specific muscle groups involved that have a measurable decrease in size or have had a prolonged period of inactivity such as with immobilization. Include the patient s progress toward short term and long term goals to restore prior level of function and mobility. Document circumferential measurements to indicate difference between limbs muscle wasting, for example in comparison to the opposite side.
2 ICD- 9 Code Diagnosis Rationale Documentation Tips 728.87 Muscle Weakness 719.7 Difficulty Walking (without surgical repair of bone or joint) 719.7 Difficulty Walking with Alzheimer s Disease This can be used for significant muscle weakness when the therapy evaluation shows 2/5 or 3/5 muscle weakness. A 3/5 weakness would indicate the need for therapy to establish a program It would be unusual that a therapy threshold would be needed to carry out the plan. 4/5 muscles weakness would not be adequate indication for the use of this. Appropriate following a hospitalization for general decrease in muscle strength, not generalized weakness. Appropriate when the patient does not have an abnormal gait but has deficits in mobility. Difficulty walking is an appropriate for an Alzheimer s patient that has had a decline in the ability to ambulate. Alzheimer s disease would then be included as a secondary. The determining factor of whether the therapy plan requires the skills of a therapist or should be taught to family or caregivers, depends on the patient s cognitive status including level of motivation and ability to remember and follow through with therapy instructions toward goal achievement. Objective tests should be documented that demonstrate the muscle weakness. POC should be directed toward establishing a home program to correct the weakness when the patient has a significant rehabilitation potential. Documentation must show why the skills of a therapist are necessary to carry out the plan. Document changes in interventions and changes in the types of exercises to support the need for therapy. Include progress toward short term and long term goals. Documentation for HEP and teaching must be clear and specific to the patient needs such as safety or use of equipment. Avoid repetitious documentation that may be reviewed as maintenance care that could have been provided by the family or home health aide, such as Patient walked 100 feet today and goal for next visit is 150 feet. Document the appropriate teaching and explanation of the HEP to the patient/caregiver. Visits that do not document the patient s continued progress may be denied for not reasonable or necessary when potential for further improvement cannot be determined.
3 ICD- 9 Code Diagnosis Rationale Documentation Tips **781.2 Abnormality of Gait for conditions unrelated to surgical interventions **781.2 Abnormality of Gait following joint replacement or fracture Appropriate when the specific gait disturbance is identified such as stepping, ataxic, paralytic, spastic or staggering gait. This is used when the condition or symptoms are associated with neurological or musculoskeletal disease process. Appropriate to use post-operative with joint replacement or fracture. When PT is the only discipline ordered use V-code 57.1 as the primary with abnormality of gait in both M0245 and as a secondary. When multiple disciplines are ordered V 54.81 (aftercare following joint replacement or V54.1 aftercare following fracture) would be used as the primary (when all disciplines are focused on the post joint or fracture care). Include the surgical procedure on the plan of care to complete a picture of the patient s status. The medical relevant to the surgery is acceptable following hip fracture or knee/hip joint replacement, but may be included as a secondary after other relevant diagnoses are included. Documentation must include the specific gait disturbance identified and the POC interventions address correction of the gait disturbance in the therapy plan and visit notes. In addition the underlying condition or symptom related to a neurological or a musculoskeletal disease must be identified. Not appropriate to use for a patient experiencing only weakness or de-conditioning due to hospitalization or from a spell of illness. Include amount and type of any therapy the patient may have received in a rehabilitation or nursing facility prior to admission to homecare. The underlying condition requiring therapy would be included on the POC as a secondary along with listing the surgical procedure to explain the patient s status.
4 ICD- 9 Code Diagnosis Rationale Documentation Tips **434.91 Cerebral Artery Occlusion with cerebral infarction **436 Acute but ill defined, cerebrovascular disease Use following acute CVA if patient is coming direct from acute care institution with goals not yet met. Stay with 434.91 until goals are met in homecare. The use of this code changed 10/04. It is now used primarily for cerebral seizures It now excludes ischemic, embolic, hemorrhagic and thrombotic CVA and strokes. It also excludes postoperative CVA (997.02) and unspecified CVA (434.91). Include history of occlusion with infarction and the amount and type of therapy the patient has already received in the acute care institution. Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement. Make sure that clinical record clearly documents that a CVA did not occur. Include any specific information on the cerebral seizure. This code will be used very infrequently due to the change in definition. 438.0 or 438.XX Late effects of cerebrovascular disease 997.02 Iatrogenic cerebrovascular infarction or hemorrhage If the patient has previously received therapy services and was discharged with goals met. Indicates conditions in categories 430-437 as the cause of late effects. Late effects may occur soon after the initial condition or arise later after healed. For a patient with late effect with hemiplegia, it is not appropriate to also list abnormal gait as it is inherent with hemiplegia to also have an abnormal gait. Coding guidelines indicate to only use symptom codes (like abnormal gait) when a definitive is not known. A CVA hemorrhage or infarction that occurs as a result of medical intervention. Also code a secondary code from the code range 430-432 or from subcategories 433 or 434 with a 5 th digit of 1 to identify type of hemorrhage or infarct. Do not use with 436. Document information on previous therapy received and goals attained. Be specific as to the type and severity of late effect. Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement. Include history of hemorrhage or infarction and the amount and type of therapy the patient has already received in the acute care institution. Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement.
5 Some V Codes may be used as primary or secondary diagnoses. When the use of a V code replaces a case mix M0245 must be completed on the OASIS, or it will result in decreased reimbursement. After December 1, 2005 V57 codes can only be used as primary in M0230 and cannot be used in M0240. V Codes Use an aftercare code for services following a fracture (closed reduction or open reduction with internal or external fixation). Include the surgical procedure on the plan of care to denote the recent surgery. The use of a V-code may replace a case mix such as abnormality of gait as the primary following certain types of fractures (for example hip or leg fractures). An aftercare code may be the primary when multiple aspects of the patient care are being addressed or multiple disciplines are involved with the care. If multiple disciplines are ordered with the focus of care related to the fracture, code as follows: M0 230 V54.1x, and 781.2 in both M0240 and M0245. When physical therapy is the only discipline ordered, place the case mix in M0245 for the correct reimbursement and also in M0240. For example: M0230 V57.1, M0245 781.2 (Abnormality of Gait), M0240 781.2, V54.1X (becomes a secondary ) V54.1X Fifth digit indicates site of fracture Aftercare for healing of traumatic fracture Can be used as a primary or secondary toward goal achievement. Include amount and type of therapy patient may have received in a rehabilitation or nursing facility prior to admission to homecare. The amount of pain and interventions to relieve pain should be noted on each visit note. Include documentation of specific gait disturbance identified when abnormality of gait is used in M0245 to obtain case mix points. The therapy plan must address the gait identified.
6 V54.2X Fifth digit indicates site of fracture Aftercare for healing pathologic fracture. Can be used as a primary or secondary V54.81 Aftercare following joint replacements Can be used as a primary or secondary. V Codes Performing care following a fracture. May involve closed reduction or open reduction with internal or external fixation or splinting. Same logic as above when PT is the only discipline providing the care. Use the same coding examples (substituting V54.2X) and sequencing when the V code replaces a case mix or other disciplines involved in care. Use additional V code 43.6X to designate the joint replaced. The use of V-codes may replace abnormality of gait as the primary for certain joint replacements (for example hip or knee replacements). Include the surgical procedure on the plan of care to complete a picture of the patient s status. V54.81 is appropriate when PT and nursing are ordered even if nursing is only for PT/INR tests. In that scenario the coding would be V54.81 in M0230 and M0240 would have V43.6X (joint replaced site) 781.2 (which would also be used in M0245), and V58.83 (encounter for therapeutic drug monitoring). If PT is the only discipline ordered V57.1 would be the primary in M0230 followed by V54.81, V43.6X, and 781.2 (which would also be used in M0245). toward goal achievement. Include amount and type of therapy patient has received in a rehabilitation or nursing facility prior to admission to homecare. Amount of pain and interventions to relieve pain should be noted on each visit note. Include documentation of specific gait disturbance identified when abnormality of gait is used in M0245 to obtain case mix points. The therapy plan must address the gait identified. toward goal achievement. Include amount and type of therapy the patient has received in a rehabilitation or nursing facility prior to admission to homecare. The amount of pain and interventions to relieve pain should be noted on each visit note. Include in documentation the specific gait disturbance identified when abnormality of gait is used in M0245 to obtain case mix points. The specific gait must be addressed in the therapy plan and visit notes.
7 V54.89 Other orthopedic aftercare Best to use either V54.1X or 54.2X when possible since they are more specific. Can be used as a primary or secondary V57.1 Physical Therapy care involving the use of rehabilitation procedures Can only be used as a primary V Codes Performing care for healing fracture, not otherwise specified. (Example: This code is used for pin care) The primary should reflect the services provided with this code as a supplemental code to describe additional services. When the POC only contains PT, V57.1 should be the first code used to justify therapy followed by V54.89 in M0240. Use as a primary when therapy is the only discipline. When multiple disciplines are involved, code the underlying condition or injury as primary and do not use the V57.1 code. Includes therapeutic and remedial exercises, except breathing. When V57.1 is used include additional code to identify underlying condition that is driving the need for rehab care. toward goal achievement. Include amount and type of therapy the patient has received in a rehabilitation or nursing facility prior to admission to homecare. Documentation must include the specific gait disturbance identified when abnormality of gait is used in M0245 to obtain case mix points. The specific gait must be addressed in the therapy plan and visit notes. PT evaluation should include the patient s specific decreased level of function and physical limitations to demonstrate the need for therapy services. Include amount and type of therapy patient has received in a rehabilitation or nursing facility prior to admission to homecare. Avoid repetitious documentation that may be viewed as maintenance care that could have been provided by the family or home health aide, such as only an increase in the number of feet ambulated or additional repetitions of established exercises.
8 V57.81 Orthotic Training Can only be used as a primary V57.89 Other Specified Rehabilitation Training Can only be used as a primary V Codes Performing orthotic and gait training in the use of artificial limbs. Add a secondary code from V49.6X-V49.7X group to identify the amputated limb site. Include the surgical procedure on the plan of care to complete a picture of the patient s status. Use additional code to identify underlying condition. Abnormality of gait may also be appropriate to use in M0245 and as a secondary when ambulation is the focus of the plan of care. Performing specified rehabilitation procedures with multiple training or therapy. Use additional code to identify underlying condition. Assign this code when PT, OT and/or SLP are included in the POC. V57.89 may also be used when there is no specific rehab code available (e.g., with pulmonary rehab), but only as a primary. Include amount and type of therapy the patient has received in a rehabilitation or nursing facility prior to admission to homecare. Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement, including the patient s compliance and follow-through with prescribed exercises. Orders and documentation must support need for skilled therapy intervention. PT evaluation should include the patient s specific decreased level of function and physical limitations to demonstrate the need for therapy services. toward goal achievement.