Home Health & Hospice Week

When you're in the market for more case mix points, look no further than a category you may have been blind to: 369.xx (Blindness and low vision). While these codes were rare in home care before January 2008, patients have always qualified for them. However, thanks to the revised prospective payment system, case mix coding has gotten more complicated and requires better comorbidity coding -- meaning you can turn to categories like 369.xx to pin down the most accurate case mix.

Warning: Now that several codes in the 369.xx category qualify for case mix points, they show up much more frequently in the top six diagnosis slots in M0230/M0240, says Judy Adams, president and CEO of Adams Home Care Consulting in Chapel Hill, N.C.

The Centers for Medicare & Medicaid Services is sure to notice this sudden change, so be certain the patient qualifies before you choose to use these codes, she cautions.

OASIS item M0390 (Vision with corrective lenses if the patient usually wears them) provides a clue that you may need to list a code from the 369.xx category, Adams says. "M0390 is actually asking about a patient's vision to identify the patient's ability to see and to visually manage (function) within his environment, wearing corrective lenses if they are usually worn," she says.

M0390 is used to evaluate any risk related to the patient's management of oral medication, by checking to see that the patient can read medication containers and select the correct amount of medication.

Low vision can also affect the patient's safety in ambulation, dressing, transfers, bathing, and other everyday functions. Poor vision can be a factor in falls risk as well.

But a M0390 response that indicates your patient has impaired vision doesn't necessarily mean it's appropriate to list a 369.xx code. Search the medical record for additional documented information beyond the M0390 score to substantiate the limitation in vision, Adams says. Look for descriptions of cataracts or other eye problems; referrals to agencies specializing in services to those with severe vision problems; or descriptions of adaptive devices the patient may be using.

The low vision must be verified by the physician and affect the patient's rehabilitation.

Why? M0390 doesn't test the patient's visual acuity, Adams points out. Loss of vision in one or both eyes must be supported by clinical findings and diagnoses verified with the physician, she says. With proper documentation, you can list a 369.xx code along with an ophthalmic diagnosis such as glaucoma, retinal detachment, or cataract to define the patient's level of visual impairment.

To legitimately list a 369.xx code, you must be able to show how the diagnosis affects the plan of care for that patient, says Conetoe, N.C.-based coding and billing specialist Vonnie Blevins. You should also code for the disease that is causing the vision impairment, she says.

Coding example: Your patient was referred to home care for instruction on diabetes mellitus and administration of insulin twice daily because she lives alone and is legally blind due to glaucoma. The clinician answered M0390 "severely impaired." For this patient, you would list the following codes, Blevins says:

• M0230a: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled),

• M0240b: 365.9 (Unspecified glaucoma),

• M0240c: 369.4 (Legal blindness, as defined in the U.S.A.),

• M0240d: V58.67 (Long-term [current] use of insulin), and

• M0240e: V60.3 (Person living alone).