Home Health & Hospice Week

Coding must adhere to the medical record, commenter points out.

A big part of the calculations leading to Medicare’s 8.01 percent behavioral cut under PDGM are based on diagnosis coding changes, and numerous commenters blasted the concept.

The Centers for Medicare & Medicaid Services’ “proposal to reduce the 30-day payment amount by 8.01 percent is concerningly high,” says David J. Totaro with BAYADA Home Health Care headquartered in Philadelphia, in the chain’s comment letter on the 2020 proposed rule. “The proposed behavior change would significantly exceed past actual behaviors exhibited by the industry since the development of the current payment system. For example, included in the assumed behavior change is an assumption that 100 percent of the time if a secondary diagnosis would result in higher reimbursement, it would be moved to the primary coding position. This level of reduction beginning on the first day of the new model is unquestionably too harsh and unnecessary in implementing this new model.”

The Johns Hopkins Home Care Group in Maryland offers CMS these statistics: For HHAs, “in 2012 the OIG identified through a sample an upcoding rate of 10.4 percent,” JHHCG’s Mary Myers says in the agency’s comment letter. “However, they also identified that agencies had downcoded at a rate of 9.8 percent, suggesting that agencies overall are not intentionally upcoding and are generally including adequate documentation to support their claims for Medicare payment.”

More stats: “With the Balanced Budget Act of 1997, the Congressional Budget Office assumed home health agencies would increase patient volume to offset revenue losses due to reduced rates. In fact, HHAs went the opposite direction and the Medicare home health patient population dropped from 3.5 million to 2.1 million in less than 2 years,” Myers points out. “Looking at previous payment models for home health services, HHPPS did observe an actual change in coding and utilization that affected payment rates, however, this was quantified to be less than 2 percent on average over seven years. In comparison, the PDGM adjustment of 8.01 percent in one year is brutal and shows a large discrepancy between what has been actually demonstrated in the industry and what CMS has imagined for 2020.”

Providers also noted the coding rules already in place that will prevent such big changes. “It is currently the requirement that the primary diagnosis be the focus of care for the Home Health episode of care,” notes Trinity Health at Home in Livonia, Michigan, in its comment letter. “So, while this change in coding behavior may occur, the degree to which this may occur and the impact of the occurrence seems to be exaggerated by CMS,” argues Trinity Health at Home’s Elizabeth Buckley in the health system-based chain’s comment letter.

“Given the current regulatory and audit environment, agencies who are coding diagnoses strictly for payment maximization must still keep their focus of care as the primary consideration in coding or their payments will be denied,” Buckley continues. “We must also recall that the home health agency can only code what is already in the medical record that has been diagnosed by a physician, so there is a limit to which diagnoses may be selected.”