Posts tagged ‘risk of falls’

December 4, 2012

CMS will not pick standardized risk of falls tool

CMS addresses valid risk of falls tools and M1910 …

Question: We see that a validation study has been published for the Missouri Alliance for Home Care’s Fall Risk Assessment Tool (MAHC-10). Does this mean that we can now use that tool as the single standardized, validated, multifactor tool to meet the “Yes” response for M1910? And if so, should the threshold of “4” or “6” be used to indicate fall risk?

Answer from CMS: Per existing guidance, if you want to report M1910 as “Yes” (that Fall Risk Assessment was conducted), you must use a multifactor standardized tool that has been scientifically tested and validated, and the tool must be appropriately administered based on established instructions. CMS does not approve or disapprove individual tools.

It is the agency’s responsibility to determine if the tool you are using includes these elements. If an agency has evidence (from published literature, the tool developer, or another authoritative source) that the tool they are using assesses multiple factors that contribute to the risk of falling, has been scientifically tested and validated on a population with characteristics similar to that of the patient being assessed, and shown to be effective in identifying people at risk for falls, and includes a standardized response scale, then the agency can consider the tool to meet the requirements for the OASIS-C best practice assessment.

In determining if a patient is at risk for falls, the standardized tool should have a standardized response scale, and/or established and validated threshold at which fall risk exists. A tool may have multiple thresholds identifying various levels of risk (i.e, “no risk”, “low risk”, “high risk”). Select Response 1 if the standardized response scale rates the patient as no-risk, low-risk, or minimal risk. Select Response 2 if the standardized response scale rates the patient as anything above low/minimal risk. If the tool does not provide various levels, but simply has a single threshold separating those “at risk” from those “not at risk”, then patients scoring “at risk” should be reported as Response 2.

See more CMS Q&As.

September 4, 2010

Watch diagnosis codes that exclude each other

Here is another question I recently received:

Question: We are having an audit, and the surveyors indicated the primary diagnosis is not supported by the secondary diagnoses: 781.2, 781.3, 728.87, V15.88, 438.84, 386.54

That the status post head injury from 20 years ago is important to the patient’s condition and abilities. We have argued this information is included in the comments, but did not see the need to code here.

This is the admission information included: 22 y/o female referred to therapy d/t decline in function and recent falls. Hx includes head trauma since age of 2 w/weakness/hypertonicity right side of body. Has had PT & OT since 2 years old. Lives w/parents, PLOF independent w/all transfers and ambulates w/o assistive device. She presents w/generalized weakness, ataxic gait & requires SBA w/transfers for safety.

Father refuses other therapy at this time.

Lisa says: This is a late effect of head injury, which means you code the residual deficits (conditions produced) first, followed by the late effects code. It appears that the patient has hemiplegia as a result of a head injury (described as weakness/hypertonicity right side of body). In addition, abnormality of gait (781.2) and ataxia (781.3) exclude each other, so they would not be coded together, nor would they be coded with hemiplegia.

Weakness and ataxia are part of the hemiplegia and would not be coded in addition. 438 is a late effects of CVA code, and the patient doesn’t appear to have had a CVA. (It is, unfortunately, common for coders to automatically think of the 438 series when coding hemiplegia, but remember that ONLY deals hemiplegia with stroke. Go to the 342 series for other hemiplegia.)

I would code this patient with 342.1x (fifth-digit decided by whether this is affecting dominant or non-dominant side), 907.0, V15.88.