M62.81 Muscle weakness (generalized)R26.2 Difficulty in walking, not elsewhere classifiedR53.1 Weakness
Principal Diagnosis Description (Index Entry)
Principal Diagnosis Rationale
Secondary Diagnosis Description
Secondary Diagnosis Rationale
Patient admitted to hospital with generalized weakness, history of recent falls and failure to thrive. Patient admitted to SNF for ongoing PT and OT.
R53.1 Weakness Weak, weakening, weakness (generalized)
In ICD-10-CM, there is not a separate code to identify admission to a long-term care facility for physical, occupational, or speech therapy. Coding Clinic 4th Quarter 2012, pages 90-98 state that when a patient is admitted to a long-term care facility for nonspecific reasons rather than a specific diagnosis, it is appropriate to assign codes for the symptoms.
R62.7 Adult failure to thrive Failure, failed; to thrive; adult Z91.81 History of falling History; personal (of); fall, falling
R62.7 RATIONALE: Patient has documented failure to thrive. Z91.81 RATIONALE: Patient has a documented history of falling.
Are we saying that "some" insurances are not accepting muscle weakness, etc as principal dx or are we saying according to coding conventions (i.e., coding clinic) we cannot use muscle weakness, etc. as principal dx? There is definitely a difference and I thought I read somewhere recently that Medicaid in Kansas was not accepting the muscle weakness, etc. But not completely sure. What is everyone's understanding on this issue and what state are you located in? Thanks to everyone.
Hi, great to see all the PDPM talk! CMS will reject all Unspecified side of the body codes if reported on MDS as Primary Diagnosis effective 10/1/19.
Unspecified side of the body to me as an auditor means the facility does not know their patient/resident very well
My state's MAC said in 2016 they were waiting for CMS directives related to Unspecified codes in LTC so I guess that is finally happening.
-Bill Roush, RHIA, BSHI, AHIMA-Approved ICD-10-CM Trainer
Thanks! Very nice to see LTC coding discussions as this is a big year for that care setting!