By Sharon Litwin January 17, 2020
When applying a diagnosis code, the most specific code that describes a medical disease, condition, or injury should be selected.
‘‘Unspecified’’ codes are used when there is lack of information about location or severity of medical conditions in the medical record. Whenever possible, use a precise code whenever more specific codes are available.
If additional information regarding the diagnosis is needed, follow up with the referring provider in order to ensure the Plan of Care (POC) is sufficient in meeting the needs of the patient.
Many of the codes that are unacceptable for primary diagnosis are because the underlying reason is not established or coded.
M54.5, Low back pain or
M62.422, Contracture of muscle, right hand
Both are site specific, but don’t indicate the cause of the pain or contracture.
CMS expects a more definitive diagnosis indicating the cause of the pain or contracture as the reason for the skilled care, in order to appropriately group the home health period. Again, remember that these can always be used as secondary diagnoses.
There are diagnosis in which it is acceptable to use an unspecified code, even as the primary diagnosis, such as CHF, i50.9, and Diabetes, type 2- E11.9. Obviously, if there is a more specific than these unspecified diagnoses, you would use those and follow the coding guidelines.
Coding Specificity: Muscle Weakness
This is a very commonly-used primary diagnosis in home health, used when Physical Therapy is ordered. CMS states that M62.81, ‘‘Muscle weakness, generalized’’ is extremely vague, and therefore, will not be accepted as a Primary Diagnosis under PDGM. “Generalized muscle weakness, while obviously a common condition among recently-hospitalized patients, does not clearly support a rationale for skilled services and does not lend itself to a comprehensive plan of care.”
In the 2008 HH PPS final rule, CMS said, ‘‘Muscle Weakness (generalized)’’ is a nonspecific condition that represents general symptomatic complaints in the elderly population”. However, until PDGM, muscle weakness has been used as a common primary diagnosis.
CMS states in the final rule 2020, that inclusion of this code, Muscle Weakness, ‘‘would threaten to move the case-mix model away from a foundation of reliable and meaningful diagnosis codes that are appropriate for home care. Clinical record documentation must describe how the course of therapy treatment for the patient’s illness/ injury is in accordance with accepted professional standards of clinical practice. Without an identified cause of muscle weakness, it would be questionable that the course of therapy treatment meets these professional standards. A more appropriate code would be one of the muscle wasting & atrophy codes as grouped into the musculoskeletal group, which indicate the reason for the generalized muscle weakness & provide more clarity for the necessity of skilled services.” (72 FR 49774)