Home Health & Hospice Week

Diagnosis Coding:

Bid Farewell To Extra Money For Certain GI Codes And More

Codes used in tens of thousands of episodes in 2012 get kicked off the case mix list.

CMS has stuck to its guns on eliminating 170 diagnosis codes from the prospective payment system case mix calculation in 2014.

This summer, the Centers for Medicare & Medicaid Services and its coding and PPS grouper contractors identified two categories of codes it wanted to eliminate from the PPS grouper. "The inclusion of these diagnosis codes in the grouper was producing inaccurate overpayments," CMS said in the proposed rule. Removing the codes from the grouper brings down the case mix average in 2012 from 1.3517 to 1.3417.

CMS wanted to ax codes that are "too acute" or that didn’t require home health treatment. The "too acute" codes represented conditions that HHAs could not appropriately care for in a home health setting, the agency said. CMS believed the codes "likely reflect conditions the patient had prior to the HH admission (for example, while being treated in a hospital setting)" and "the condition progressed to a less acute state, or is completely resolved for the patient to be cared for in the home setting."

The codes not requiring services "would not impact the HH plan of care (POC), or would not result in additional resource use when providing HH services to the patient," the proposed rule said.

Providers seemed fine with some of the codes getting ditched. A number of the codes "shouldn’t have been in there," acknowledges financial expert Pat Laff with Laff Associates in Hilton Head Island, S.C.

But commenters protested getting rid of many of the codes. In the "too acute" category, pro-viders and industry reps lobbied to keep codes for GI ulcers and gastritis (531-535), Diverticulitis/di-verticulosis (562), Hemorrhage of GI tract (578.9), Post-hemorrhagic anemia (285.1), Peritonitis (567. 21), Peritoneal Abscess (567.22), Liver Abscess (572.0), and Acute pancreatitis (577.0), among others.

In the second category, commenters wanted to keep Esophageal reflux (530.81), Restless leg syndrome (333.94), and Sickle cell trait (282.5), they said in letters commenting on the proposed rule. (See Eli’s HCW, Vol. XXII, No. 36 for more details on the code removal.)

In the 2014 HH PPS final rule published in the Dec. 2 Federal Register, CMS shoots down commenters’ many objections and finalizes the 170 codes’ removal from the grouper effective Jan. 1. "The removal of the 170 codes encourages compliance with ICD–9–CM coding guidelines and ensures that conditions that are either too acute to be treated in a home health setting or do not represent the resources assigned to a diagnosis group are removed from assignment to one of our diagnosis groups within the HH PPS Grouper," CMS says. "The removal of these codes is appropriate, either because these conditions cannot be appropriately treated in a home health setting, or because these conditions do not impact the home health plan of care and result in overpayments to HHAs."

Examine Your Claims For These Commonly Used Deleted Codes

In Table 3 of the final rule, CMS lists the deleted codes most used in 2012. The top deleted codes used were:

1. 401.0 (Malignant essential hypertension), 34,207 episodes;

2. 285.1 (anemia mentioned above), 26,547 episodes; and

3. 578.9 (GI tract Hemorrhage mentioned above), 23,650 episodes.

Note: See a list of the deleted codes in Table 2 of the final rule at www.gpo.gov/fdsys/pkg/FR-2013-12-02/pdf/2013-28457.pdf.

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