Official Coding Guidelines December 1, 2005 Change How We Look At Therapy
Official Coding Guidelines to coincide with changes to the codes that were effective October 1, 2005 were published on November 21 and were effective December 1, 2005. Although there is additional information in the guidelines regarding some of the new codes that may provide additional insight into coding, the most significant of the changes impacting home health care are the changes to the V Code Table. The Official Coding Guidelines are not in your 2006 book, unless your publisher sent you updated pages to replace those in the book.
The V Code Table indicates which V codes may be first listed or primary; either first or additional (primary or secondary); and additional only (secondary only). Although there are several changes, only those changes that impact home health care will be discussed.
Keep in mind that V codes indicate a reason for encounter. The usual situations that V codes are used in home care include when “a person with a resolving disease or injury, or a chronic, long term condition requiring continuous care, encounters the health care system for specific aftercare of that disease or injury... A diagnosis/symptom code should be used whenever a current, acute, diagnosis is being treated…” (Official Coding Guidelines, Effective December 1, 2005, page 47 or 77) V codes are also used in home care when “circumstances or problems influence a person’s health status but are not in themselves a current illness or injury.” (ibid p. 48 of 77)
V57 Care involving use of rehabilitation procedures
The code category V57 has been moved from the “First or Additional” list to the “First Listed” list. This means that V57 codes may be placed in M0230 only. V57 codes may not be placed in M0240. This change does NOT mean that anytime therapy is provided, that the appropriate V57 code must be coded as primary. Guidelines for selecting the primary diagnosis and sequencing still apply.
If only rehabilitation services are being provided for a resolving disease or injury, or a chronic, long-term condition requiring continuous care then the appropriate V57 will be coded as primary. If a current, acute diagnosis is being treated then that diagnosis should be coded as primary. In that case, according to the Guidelines, the V57 codes would not be coded at all.
This is the change that impacts home care the most. The change is good for a number of reasons. First, risk adjustment is not impacted by V codes so the “freeing up” of M0240 spots for other numerical diagnoses will help to improve the risk adjustment on the diagnoses and possibly impact the outcomes. Second, coders will have to think harder and make better decisions on whether V57 should be primary (it is now primary 25% of the time which is out of sync with what should be happening).
What impact will this change have on billing? It should have no impact. The Regional Home Health Intermediaries (RHHI) will still know when therapy has been provided by the revenue codes and visits logged on the final claim. The HIPPS code contains an ‘L’ or an ‘M’ in the 4th position when the therapy threshold has been met.
Home care agencies will probably increase the use of V57.89 multiple training or therapy. In the past, some coders have resisted the use of V57.89 because it took away the specificity of coding all the therapies. Now that we can code the V57 codes in M0230 only, if we are providing more than one therapy, then we will be more likely to use V57.89 as primary.
This change affects the entire category of V57 for physical therapy, occupational therapy and speech therapy, in addition to multiple therapies.
The patient is receiving physical therapy only after a fracture to the hip. V57.1 would be coded as primary.
The patient is receiving PT, OT and nursing after a joint replacement. V54.81 would be coded as primary, followed by the appropriate V43.6x code to indicate the joint. V57.1, V57.21 and V57.89 would not be coded at all.
If nursing and therapy are both caring for the patient, don’t count the number of visits to determine “who” will be first. Instead, look at the conditions being treated and code the most acute condition requiring the most intensive services. Choose the condition that reflects the chief reason for home care; not the V57 code.
V58.6 Long term (current) drug use
The V58.6x codes are now secondary only. These codes have always been considered status codes so this change may not be a surprise to many. The code means the patient is taking the drug, not that the provider is doing anything with it, so it should not be coded as primary.
The Guidelines provide some additional information about the use of this code. They state on page 50 of 77: “Assign a code from subcategory V58.6, Long-term (current) drug use, if the patient is receiving a medication for an extended period as a prophylactic measure (such as for the prevention of deep vein thrombosis) or as treatment of a chronic condition (such as arthritis) or a disease requiring a lengthy course of treatment (such as cancer). Do not assign a code from subcategory V58.6 for medication being administered for a brief period of time to treat an acute illness or injury (such as a course of antibiotics to treat acute bronchitis).”
This guidance may not be the clarification you need, but remember this if your patient will take the medication for an extended period of time or is taking it prophylactically, perhaps you should code the code. Ask yourself: “Is it clinically logical to code it?”
V15.88 History of Fall (at risk for falling)
Falls are an important public health problem affecting about one third of adults 65 and older each year. Approximately 20-30% of those who fall will suffer moderate to severe
injuries, including hip fractures and head trauma. Fall-related injuries can reduce mobility and independence and often are serious enough to result in hospitalization and
increased risk of premature death. In 2001, over 1.6 million older adults were treated in
emergency rooms for fall-related injuries, and 373,000 were hospitalized. Adults aged 75 and older who fall are more likely to be admitted to a long-term care facility for a year or longer. In this same population over 60% of deaths are from falls.
V15.88 has been designated as a “First Listed or Additional” code. This code may be used to indicate a decision to order preventive evaluation or services or just to identify a patient at risk. Many patients who report they have fallen may not have suffered an injury but statistics show that those who have fallen in the past year, or have a history of falls are much more likely to fall resulting in serious injury. Once patients with a history of falls or other risk factors are identified, interventions are effective in lowering the incidence of falls causing serious injury.
The use of V15.88 could be advantageous in some instances. With a V code in M0230, M0245 is available to use any case mix diagnoses that may be related to an injury.
V49.6x and V49.7x Upper Limb Amputation Status and Lower Limb Amputation Status
The V40 series of codes are status codes. Status codes are usually for additional information only and are usually secondary only. The V code table moves these two subcategories to the “First or Additional” list.
Amputation status is likely important to any plan of care so can be coded any time a patient has had an amputation recently (providing aftercare) or if they have had an amputation in the past. In fact, the Coding Clinic names these codes as a co-morbidity that should always be coded, even in the absence of intervention. If the amputation is complicated because of a neuroma or an infection, then the status code should not be used. The complication code 997.6x should be used instead.
The Official Coding Guidelines affect all payors and providers. Even though this article referred to M0230 and M0240, the same concepts apply to those not completing OASIS. The new Official Coding Guidelines can be found at: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide05.pdf