Home Health & Hospice Week

Careful diagnosis coding may be essential, experts say.

Take a close look at the latest Work Plan from the HHS Office of Inspector General. Your Medicare profit margin could depend on it.

Of the six items included in the Work Plan's section on home care, agencies should pay particular attention to a new area of investigation: The OIG plans to explore home health agencies' ability to code claims for Medicare Home Health Resource Groups (HHRGs).

The spotlight will be on the accuracy of coding, experts say.

The OIG will be trying to ascertain "the extent to which providers improperly code HHRGs and the level of inappropriate payments made as a result of any miscoding," according to the work plan.

At this point, the OIG's precise focus is a bit of a mystery.

Likely target: While "it is difficult to tell what is going to be monitored, the accuracy of diagnosis coding on the OASIS may be a prime target," offers Burtonsville, MD-based health care attorney Elizabeth Hogue.

Don't Inadvertently Upcode

To steer clear of unwanted scrutiny, the diagnoses you report on your claims need to support the reason for delivering the service. This is especially true because the claim is the only thing that your fiscal intermediary sees; they don't see the OASIS or the plan of care, advises consultant M. Aaron Little with BKD in Springfield, MO.

Example: A claim had a primary diagnosis of diabetes and the HIPPS code reflects the points for diabetes. But the documentation shows the focus of the care is a venous stasis ulcer. The claim is coded incorrectly as 250.80 (Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled) followed by 454.0 (Varicose ulcer [lower extremity, any part]).

Venous stasis ulcers are not manifestations of diabetes, so coding diabetes as the primary diagnosis is upcoding.

If you submit a claim with an inaccurate diagnosis code, your intermediary could subject the claim to the increased scrutiny of a medical review, notes Little. For instance, your fiscal intermediary may have an edit in place for claims with a primary diagnosis of 781.2 (Abnormality of gait). If you submit a claim with 781.2 as primary when 719.7 (Difficulty in walking) is actually a more accurate code choice, your claim may be pulled for review.

Big risk: Reporting inaccurate diagnosis codes will slow down your payment. It costs time and money as you provide additional requested documentation--and you may even have to go through an appeals process, Little warns. All this can be prevented if your agency simply makes certain that the diagnoses codes billed are accurate and agree with medical documentation.

Best defense: Even with the OIG's lack of detail about what data it plans to monitor, agencies will do well to step up training related to OASIS and diagnosis coding, adopting the "best defense is a good offense" approach to compliance (For tips on diagnosis coding and claims, see "Brush Up On Coding Skills To Keep Claims On Track").

Internal audits of OASIS accuracy can flag potential trouble spots. Once you're sure you're getting diagnosis coding correct on the OASIS, be sure that you're translating that data correctly to the care plans and claims.

Double whammy: It's likely that the OIG's efforts will be followed by scrutiny and enforcement action by the Centers for Medicare & Medicaid Services, notes the National Association for Home Care & Hospice in a review of the plan.

Look for more information about possible audits soon. The OIG aims to report to Congress on the issue in fiscal year 2008.

Note: To review the OIG Work Plan, go to www.oig.hhs.gov/publications.html.