Home Health & Hospice Week

CMS won’t budge on excluding muscle weakness.

While Medicare officials made some tweaks to PDGM’s diagnosis codes, most of them remained as-is — including some top codes frequently used by home health agencies.

Numerous commenters on the 2020 proposed rule urged the Centers for Medicare & Medicaid Services to add M62.81 (Muscle weakness (generalized)), R26.89 (Other abnormalities of gait and mobility), and other frequently used codes to the Patient-Driven Grouping Model’s case mix system.

But for the most part, CMS stands by its decision not to include even the most popular codes if they are too vague or just describe symptoms. “In accordance with ICD-10-CM coding guidelines, the principal diagnosis reported is that ‘condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care,’” the agency reminds in the rule. “By the time an individual is admitted to home health,” CMS expects “the patient has been seen by other health care providers and a diagnosis has been established.”

“Nonspecific, ill-defined” symptom codes preclude development and implementation of a “comprehensive, individualized patient-centered” care plan, CMS insists. “Accurate documentation and diagnosis reporting is essential to ensure that an individualized plan of care is established to meet the patient’s home health needs.”

That explains CMS’ dismissal of these popular codes for which commenters advocated: R29.6, (Repeated falls), R00.1, (Bradycardia), R41.82 (Altered Mental Status), R42 (Dizziness and giddiness), and R27.0 (Ataxia). “The majority of the R-codes (codes that describe signs and symptoms, as opposed to diagnoses) are not appropriate as principal diagnosis codes for grouping home health periods into clinical groups,” CMS argues in the rule.

“The home health referral may be nonspecific or … the physician may be in the process of determining a more definitive diagnosis,” CMS allows. “However, with respect to patient safety and quality of care, we believe it is important for a clinician to investigate the cause of the signs and/or symptoms for which the referral was made. This may involve calling the referring physician to gather more information.”

CMS maintains that “ill-defined conditions are limited for those circumstances where there is no recorded diagnosis that is classifiable elsewhere. However, patients are referred to home health from other clinical settings (either from a facility or a community-based provider) and therefore, we believe that the medical records from such referral source should provide information as to the need for home health services, including the diagnoses established by such providers. Clinically, this information is needed to develop the individu­alized plan of care with patient-specific goals.”

Do this: “HHAs should query these referring providers to ensure they have a clear understanding of the conditions affecting patients in need of home health services,” CMS instructs.

CMS sets aside the most space to address the requests for M62.81 (Muscle weakness …). The code ranked number-one as agencies’ non-valid primary code in 2017, according to industry data analysis. In fact, it ranked third in overall primary code usage that year.

M62.81 “is a vague code that does not clearly support a rationale for skilled services,” the rule insists. “Further, the lack of specificity for this code does not support a comprehensive plan of care.”

CMS disparages the code even further. For therapy, “if there is not an identified cause of muscle weakness, then it would be questionable as to whether the course of therapy treatment would be in accordance with accepted professional standards of clinical practice,” the agency warns in the rule.

CMS’ dismissal of these codes is “very disappointing” to many providers that have at least a few of them in their “top 10,” says coding expert Joan Usher with JLU Health Record Systems in Pembroke, Massachusetts. Don’t overlook CMS’s attack of the services’ medical necessity based on the codes’ vagueness, Usher cautions.

Remember: Once PDGM hits, claims with M62.81 or other non-valid codes will return to provider, delaying cash flow. (For tips on dealing with this code’s demise, see story, p. 336.)

Multiple commenters told CMS that home health access would be threatened if they didn’t include the symptom or other codes.

CMS’s response is to just calm down. “A patient’s principal or secondary diagnoses are not sole factors in whether a patient is eligible for Medicare home health services,” the final rule maintains. “As such, eligible beneficiaries are entitled to their Medicare home health benefits and we do not expect there to be an access to care issue.”

Further, “the clinical group is just one variable in the overall case-mix adjustment for a home health period of care,” CMS reminds providers.

And PDGM actually includes more diagnosis codes than the current PPS case mix system’s clinical dimension, CMS adds in the rule.