The Regulations and Reimbursement area of this website presents resources to assist the clinician in defining the practice of therapeutic interventions with patients with dementia. This monthly article presents a synopsis of correct coding to help insure reimbursement.
Sample coding when Dementia/Alzheimer's is the only primary medical diagnosis
We often see a patient who is having trouble eating (i.e. excess spillage, decreased intake, etc.) or otherwise not participating in daily life tasks, and there is no internal referral from nursing to identify a significant change. Unfortunately, few facilities identify a patient/refer a patient who presents with "potential for improvement." The primary medical diagnosis in the chart may indicate dementia or Alzheimer's with maybe nothing else besides Hypertension. The trained therapist recognizes quality of life and burden of care issues, which may indicate the need for skilled therapy intervention.
The therapeutic intervention may be through the evaluation and development of a Maintenance Program. In this case the therapist evaluates, develops a program that achieves the desired result, and trains the caregiver to continue implementation. Or the intervention may be through more direct treatment to achieve the goal, followed by caregiver training.
How to proceed
Screening and referral:
The MDS reports in Section G7, whether or not a plan is in place for "Task Segmentation" for ADLs. Also in Section G8 are questions relating to "ADL Functional Rehabilitation Potential." These are important areas to review and use the wording in documentation. Communication with the MDS coordinator is necessary to change or support the reporting.
The questions in Section G8 are:
"Resident believes he/she is capable of increased independence in at least some ADLs."
"Direct care staff believe resident is capable of increased independence in at least some ADLs."
"Resident able to perform tasks/activity but is very slow."
"Difference in ADL Self-Performance or ADL Support, comparing mornings to evenings."
The therapist, upon screening and as part of the care team, may indicate for the 2nd item (b) that the resident is capable of increased independence in at least some ADLs. In some cases, the resident may express the desire to do more in a task. The documentation of this first step should be entered into the medical record and the wording included in the initial evaluation under "reason for referral."
While the primary medical indicates a cognitive impairment, the treatment diagnosis will focus specifically on the areas to be addressed. As much as possible, avoid the use of the following ICD.9 Codes:
728.87 Muscle Weakness
780.99 Decreased functional activity
799.3 Debility unspecified
The following are more specific and supporting ICD.9 treatment diagnoses that could be used. (Please note the treatment diagnosis follows a thorough evaluation to determine the root cause of the ADL difficulty. A dementia diagnosis does not mean a patient is predetermined to be weak or totally dependent.) More than one treatment diagnosis may be used.
368.9 Visual disturbance, unspecified. This is physical and not related to the cognitive field of recognition.
388.01 Presbycusis. Hearing loss related to advancing age. This may affect the type of cueing necessary for a patient.
719.0 Joint pain and stiffness for multiple areas. A common and maybe undetected area that impedes participation.
719.7 Difficulty in walking. This may be coupled with other codes to define why the difficulty in walking is happening.
728.2 Muscle wasting and disuse atrophy. Lack of purposeful activity may contribute to this.
780.79 Other malaise and fatigue. This may appear as a symptom of a dementia diagnosis due to lack of involvement in daily tasks.
781.3 Lack of coordination.
781.92 Abnormal posture.
782.0 Disturbance of skin sensation (may be medicine related).
783.21 Abnormal weight loss.
783.3 Feeding difficulties.
The specific choice of the treatment focus defines the interventions and supports the "reasonable and necessary" justification for therapy. Defining the patient with "decreased functional activity" gives no indication as to why it is happening. The code chosen is also a reflection on the clinical reasoning skills of the therapist.
97535 Self care and compensatory training
97530 Therapeutic activities, dynamic
These two codes are overused in the treatment of dementia-related interventions.
A task analysis of the treatment approach is essential in a thorough course of treatment. While the above codes may come into play, try considering a more defining intervention. Just as the choice of a specific treatment diagnosis is guidance to the root cause, the choice of intervention techniques is a self-examination process for the therapist and also creates supporting documentation for "medically necessary & reasonable/necessary."
Consider these other possible procedures:
90901 Biofeedback by any method. This refers to any tactile, auditory, visual, sensory stimuli for the purpose of neuromuscular retraining. May be used for Level 4 and above.
95831-95834 Manual muscle testing series. These are not to be used with other evaluation codes but may be used to test after a course of treatment.
95851-95852 Range of motion codes. Precautions as above.
97110 Therapeutic exercise is to be used only when the goal is increased strength, endurance, range of motion.
97112 Neuromuscular re-education. May be used to establish new functions. May be used with mid to high Level 4 and above.
97140 Manual therapy techniques. Includes soft tissue mobilization, joint manipulation, traction/compression. This is advised to be used as a preparatory technique before exercise.
97532 Cognitive skills development. Includes compensatory training for memory, problem solving, and attention span in order to function in ADLs. Can be used to structure routines.
97533 Sensory integrative techniques. Includes enhancement or adaptation of sensory processing to environmental demands when decreased sensory motor and behavioral responses are present.
Note: Time spent providing caregiver training is attributed to the goal or technique being shared.
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The quality and effectiveness of therapeutic intervention can be defined by the codes chosen. Consistently indicating only "decreased function" for treatment is a reflection of the therapist's evaluation skills. The clinical reasoning involved in a course of treatment is defined by choice of CPT codes. The population with dementia-related diagnoses does not have to be viewed with a presumption of fast decline, or with no possibility for improvement.
Both ICD.9 and CPT code choices direct the focus of the therapist and support the need for skilled intervention. Quality of life for our patients is in the eyes and beliefs of the caregiver. You are the therapist who can make that possible.
Authored by: Mary L. Gennerman, OTR/L
References: ICD.9 and CPT code references can be found in the Regulation & Reimbursement section of this website.
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