DRG Coding Advisor: Coders may have difficulty dealing with rehab coding

Medicare documentation requirements confound most coders, errors result in denials

Coders whose work includes coding for an inpatient or outpatient rehabilitation facility may find that their work is complicated because of some of the documentation and coding conflicts that arise when facilities seek reimbursement.

"Medicare is so specific about what [it wants] to see, and therapists are still behind the curve on their documentation," says Danna Mullins, PT, MHS, president of Encompass Education Inc., a rehab education consulting company of Palm Harbor, FL.

Mullins offers these suggestions for improving rehab documentation across the care continuum:

1. Focus on the regulations.

Coders need to know what Medicare is telling fiscal intermediaries to look for in therapy documentation.

"You have to understand that Medicare is no longer looking at Part A claims as a single service," Mullins says. "Medicare doesn’t review physical therapy in a rehab claim; the agency looks at the entire claim to see that the patient got what was needed from the facility."

Under the new regulations governing skilled nursing facilities, rehabilitation hospitals, and other health care entities, Medicare now asks for more than the therapy notes. Facilities will have to provide nursing notes, discharge history, and the doctor’s notes.

"Medicare wants to make sure that the order sheet matches what the therapist is doing, and if there are discrepancies between the therapy notes and nursing notes, then Medicare will dig into that chart," Mullins explains.

2. Consolidate progress notes.

"We’ve also been made aware recently that there are times when Medicare is looking at a chart where therapy notes don’t show progress for a patient," Mullins says. "But the nursing notes show the patient needed help initially and now does not need maximal assistance, so the patient is showing improvement."

Coders need to be aware of how nurses have coded these activities and make certain they fit together. "Patients may have reached a leveling off point in therapy, but they may have improved during the other 23 hours of the day," Mullins says. If that’s true, then it should be coded in a way that reflects patient improvement.

3. Identify primary diagnosis.

Medicare has very specific requirements for making diagnoses and setting functional goals.

"A big source of confusion is the diagnosis," Mullins says. "The primary diagnosis for Part A Medicare is a different diagnosis for Part B."

In Part A, the primary diagnosis has to be the diagnosis for which the patient was receiving hospital care or treatment. Under Part B, the primary diagnosis is the medical diagnosis that has resulted in the therapy disorder.

For example, suppose a patient is admitted to the hospital for coronary artery bypass graft. The patient also has rheumatoid arthritis and begins to have difficulty with bed rest. It’s likely the patient will need physical therapy at the nursing home when the heart surgery is finished, Mullins says.

It’s obvious that the therapist will not be treating the patient’s heart disease, but that’s the primary diagnosis in the skilled nursing facility under Medicare Part A.

On the other hand, if the same patient is receiving outpatient therapy services, the primary diagnosis is rheumatoid arthritis under Medicare Part B.

4. Watch for red flags.

Coders may catch possible coding errors by being aware of some of the more common problems that Medicare says are primary diagnoses and not procedures.

Coders should remember: If it’s Medicare Part A, the primary diagnosis, regardless to whether it’s related to the treatment described, is what has to be coded. For Medicare Part B, the primary diagnosis should be something that can be treated with therapy if therapy is the service described.

"On the other hand, there are diseases, and diabetes is a good example, where codes will go beyond the diabetes," Mullins explains. "There’s a code for diabetes with neurological manifestations that a therapist might be involved in treating, and there’s a code for diabetes-related peripheral circulation disorders, and a physical therapist might be doing wound care because of this."

In these cases, coders would not want to use the general diabetes code, but would instead use the codes that better describe the particular diabetic problem.

5. Understand the gray areas.

Often there is no easy way to determine which code will work best.

For example, one common dispute is about how to code cerebral vascular disease. Some coders don’t want to use ICD-9 438 code because it’s called the "Late effects of cerebral vascular disease."

"There’s this misinformation out there that late effects means something that happens weeks or months down the road, when in fact the way the coding works it can [mean] anything that happens after a cerebral vascular attack (CVA) is a late effect," Mullins explains.

So aphasia or hemiplegia are all late effects because they didn’t happen at the moment the CVA occurred, she adds.

Then there is the ICD-9 436 code which is for acute, but ill-defined cerebral vascular disease. This code includes a CVA that can’t be attributed to a specific cause, such as aneurysm or thrombosis.

Coders also need to find out enough detail to be very specific with the 438 codes, as these are dependent on which side is affected by hemiplegia and other effects of CVA, Mullins says.

For example, ICD-9 438.10 denotes aphasia after a CVA; 438.11 refers to dysphasia. When the hemiplegia affects the dominant side of the body, the code is 438.21, and when it affects the non-dominant side the code is 438.22.

"If hemiplegia affects the dominant side then it’s likely that therapy will continue longer because this will affect handwriting, eating, dressing oneself, and all of the activities of daily living will take longer to regain full function or potential," Mullins says.

Describe goals in real-life terms

6. Clarify functional goals.

It’s important to show functional goals for Medicare patients.

"By this we mean something that is practical for that patient to be able to do in his daily life," Mullins says.

For example, if the goal is written down for the patient to have knee flexion from zero to 120 degrees, that would not be a functional goal.

Instead the therapist’s notes should say that the patient will be able to stand independently, which is a functional goal.

Likewise, it’s not enough to say that the patient will walk 75 feet. Instead, it should be stated that the patient will walk 75 feet from the bedroom to the kitchen.

Also, Medicare wants the plan of treatment to include reasonable estimates of when the goals will be reached and what specific modalities and procedures will be used.

When coders are presented with incomplete therapy notes and information, they need to return to the therapists and tell them exactly what Medicare requires them to include in their plan of treatment, Mullins suggests.

This won’t necessarily require a new documentation form, but it does mean that clinical staff need to understand what Medicare wants and how to modify any information that doesn’t include these objectives.

For instance, all progress notes and plans of treatment should include at least these three items:

  • identification of skilled services provided;
  • patient response to those services in objective terms;
  • progress made toward functional goals.

7. Use Medicare’s instructions.

Coders who would like to learn more specifics about Medicare’s requirements may download the chapter six of Medicare’s program integrity manual from the web site: http://cms.hhs.gov/manuals/.