Weakness as Primary for Home Health
Recently we have had a lot of MD's listing Generalized Weakness on their MD notes for patients who are released from facility, swing bed, etc after being treated for a diagnosis that is now resolved(Pneumonia, UTI). The clinicians are then listing Weakness as the primary reason for home care. I have been coding home health for 10+ years and was always told not to use Weakness as a Primary as it is very nonspecific. Can anyone guide me to any current talk of this topic? I find articles in Decision Health from years back about not using symptom codes but nothing recent. There is a debate among my fellow coders that there is not specific information stating not to use Weakness as primary.
Comments
Hi there. Weakness (R53.1) is a "questionable encounter" code. Assigning a questionable encounter code as a primary diagnosis code on a claim can result in a Return to Provider (RTP), meaning that the claim needs to be corrected and resubmitted, delaying payment. Also, a HIPPS code, required for payment, cannot be calculated without the assignment of a PDGM acceptable code as primary on a claim.
There is an article discussing this further from last year: https://codingcenter.decisionhealth.com/MVC/DCP/Detail?id=547865&tab=1
Hope this is helpful
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