Resolved Home Health Coding

[SarahK_58488]

Hello All,
I am coding for home health, if the referral from the provider does not have a definitive dx, are we able to look at the therapy notes and code the dx the therapist has determined? My understanding is that they would be an approved clinician and ok to glean a dx from, even if that dx is not included in the referral documents from the referring provider. I guess what I am asking is what are the appropriate documents that I can obtain a primary and secondary dx from, if ony weakness or gait instability come over on the referral and reason for visit? Thank you in advance!

 

[Alicia]

Therapy is approved. You are looking for the reason for the weakness or gait instability in the note. MSN is also approved providers.

 

[Darcy]

Hello All,
I am coding for home health, if the referral from the provider does not have a definitive dx, are we able to look at the therapy notes and code the dx the therapist has determined? My understanding is that they would be an approved clinician and ok to glean a dx from, even if that dx is not included in the referral documents from the referring provider. I guess what I am asking is what are the appropriate documents that I can obtain a primary and secondary dx from, if ony weakness or gait instability come over on the referral and reason for visit? Thank you in advance!

What is the referral specifically for?

 

[SarahK_58488]

Therapy is approved. You are looking for the reason for the weakness or gait instability in the note. MSN is also approved providers.

Perfect, so if it is not clear on the referral and initial encounter documents. I can look at therapy notes to determine the reason, and use what they have selected for the primary. Am I understanding that correctly?

 

[SarahK_58488]

What is the referral specifically for?

Weakness or gait instability

 

[Darcy]

Weakness or gait instability

Is the referral for physical therapy or home health care?

 

[SarahK_58488]

Assessment - Physical Therapy: PT is a 71 y/o male admitted with acute encep, naus/vom. Pt hx of Parkinsons. Pt is limited by Parkinson rigidity, le weakness, confusion improved. Pt will benefit with continued skilled therapy to improve mobility and safety. Recommen HHPT.

In this case the primary would be the enceph or the parkinsons/le weakness?

 

[SarahK_58488]

Is the referral for physical therapy or home health care?

Home Health Care PT

 

[Alicia]

Your dx is parkinsons/le weakness. Because you are not tx for encep.

 

[SarahK_58488]

Thank you all so much for your review, that was really helpful!