R54
Do I need to have the provider specifically state "age-related debility" or "senile debility" in order to use this code? Or can I use this if the patient is over 60 and has documented debility with, for example, severe dementia? I would appreciate your thoughts on this since I think I would get some frustrated responses if I tried querying for the specificity of the debility.
Comments
Following the alphabetic index, yes, the debility would need to be specified in order to assign R54 because the subterms 'old age' and 'senile' are essential terms. Without these terms, the default is the main term 'Debility' term with R53.81. Remember, non-essential modifiers are within parentheses, meaning the terms within parentheses after a term or subterm may or may not be included in the diagnostic statement.
Are there some clinical indicators that could be used to query for R54?
Recent presentation of a 83 yr old elder with the following documentation: Admit for observation s/p fall, due to pt.s frailty, home alone status and medical comrobidities.
2 days later covering physician changed to IP with this doc: Reason for admission is physical deconditioning. . ." Meditech codes physical deconditioning as R53.81(other malaise). I cannot get to that code in 3M with the term deconditioning or via the index in ICD 10 CM.
Fraiity as documented in H/P and now in later PNs (attending changed back to admitting physician), codes to R54 per the index in ICD 10 CM and per the index.
If weakness is the diagnosis, 3M also offers age related as a option. I don't see "age related" under weakness in the index, only senile that leads to R54.
Thoughts on this? Does anyone query for age related physical debility or frailty? R54 leads to a completely different DRG (884 organic disturbances and intellectual disability) than does malaise or generalized weakness (947-948, Signs and symptoms).
Thank you! I come across this quandary with weakness in the elderly population on a semi regular basis.