Home Health & Hospice Week

As controversy over Attachment D diagnosiscoding guidance continues to swirl, the feds areinsisting it's no big deal.

Chief concerns were when to use case mix codes in M0246 when there was a V code in M0230 and what happens to risk adjustment if the code that used to go in M0246 isn't there (see Eli's HCW, Vol.XVIII, No. 5, p. 36).

At the recent National Association for Home Care & Hospice March on Washington conference inWashington, D.C., CMS's Lori Anderson said agency officials found the controversy surprising. Attachment D merely reiterates longstanding coding guidance from CMS on sequencing and adds some new opt-outs that should simplify M0246 coding,Anderson insisted.

Old way: CMS used to direct agencies to put a case mix code inM0245 (the item before it was changed to M0246 last year) any time a V code replaced it in M0230.

New way: Now CMS tells agencies to put a case mix code in M0246 in only three specific circumstances: when the replaced case mix code is in the Diabetes, Skin 1, or Neuro 3 PPS diagnosis groups; when the V code replaces a case mix code that is a resolved condition; and when the V code replaces a fracture code.

"Nothing [bad] is going to happen if you code M0246" under the old rules, Anderson noted in the session. It's merely a waste of time to code M0246 when the payment system will pick up the case mix points elsewhere due to changes made in the prospective payment system refinements that took effect in January 2008.

"There simply isn't a need to code M0246"in most cases, Anderson told attendees. Think of coding the item as "optional," except in the three narrow circumstances laid out by CMS.

No worries: Failing to have the case mix code in M0246 shouldn't affect risk adjustment for outcomes either, Anderson maintained. You should list the case mix code in M0240 on the OASIS form anyway, and the more complex PPS system should pick it up for risk adjustment there, she said.

As for sequencing guidance, that hasn't changed, Anderson insisted. Home health coders should place diagnoses in the order that best reflects the seriousness of the patient's condition, she advised.

Not so fast: Home health agencies aren't convinced that the new guidance is as harmless as Anderson claimed. "The issues and concerns [agencies have] haven't been resolved" by CMS's assurances, says NAHC's Mary St. Pierre.

Coding experts still contend that risk adjustment is affected by the new Attachment D guidelines,St. Pierre notes. And some of the coding scenarios appear to contain errors.

Attachment D guidance will lead to lower case mix scores for HHAs, maintains consultant Pat Laff with Laff Associates in Hilton Head Island,S.C. Anderson's explanation "didn't hold much water," says Laff, who attended the session.