Home Health & Hospice Week

Start training now if you hope to be ready for PPS refinements by January.

Your diagnosis coding accuracy will be more important than ever under the proposed prospective payment system refinements, so you'd better make sure your coding is up to speed or risk losing major reimbursement.

Of the changes to PPS' clinical domain, "the biggest challenge is going to be the diagnoses," predicts Chicago-based regulatory consultant Rebecca Friedman Zuber. Agencies will risk "leaving money on the table by not including all of the relevant diagnosis codes," Zuber worries.

Here are four major coding changes, included in the April 27 proposed rule, that could torpedo your reimbursement if you don't know your coding ropes:

• An expanded list of case mix diagnosis codes. The Centers for Medicare & Medicaid Services wants to increase the current four case mix diagnosis groups (neurological, orthopedic, diabetes and burns and trauma) to 20 new groups with hundreds of codes.

• An expanded OASIS form with space for six diagnosis codes. PPS will count the diagnosis codes in the primary and secondary positions toward case mix. And PPS will count the diagnosis codes in all six positions when used in conjunction with a M0 item that requires an accompanying diagnosis code to add points to the case mix.

• M0246 will replace M0245 and allow for a replacement code when a non-paying V code bumps a case mix code out of the primary or secondary position.

• Scoring will be cumulative instead of just counting the highest-paying diagnosis group, as agencies do currently.

(For details on coding changes in the PPS proposal, see Eli's HCW, Vol. XVI, No. 16.)

The coding guidelines themselves will stay the same, experts allow. Home health agencies have always had to abide by ICD-9 coding rules, points out Abilene, TX-based reimbursement consultant Bobby Dusek.

But "we now have to master a multitude of additional diagnoses at all six positions," stresses consultant Pam Warmack with Clinic Connections in Ruston, LA. "Several codes will only capture points if in combination with additional OASIS items," she highlights. "This may be difficult for the nurses to keep in mind when deciding which codes to utilize or the order in which to place the codes."

Know the score: Figuring out the re-imbursement impact of your coding choices will get much more complex under the PPS proposal, Dusek says. Diagnosis codes can garner a much broader point score than just the current 11, 17 or 20 points for M0230/ M0240/M0245 or 21 points for M0440. Under the proposed changes, many diagnoses add as little as one point and some add as much as 15 or 20 points.

In fact, the proposed PPS changes follow the current M0440 model. The new PPS will tie many OASIS items to diagnosis codes to receive payment. "The emphasis is off the M0 items and toward diagnosis," believes consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN.

Example: An answer of 2 or higher in M0690 on transferring gets points only if it's paired with a neuro case mix diagnosis. With some of the options garnering up to seven points, that can make a big reimbursement difference.

Because of the complexity, many agencies won't be using diagnosis codes and OASIS codes together to get the reimbursement that's rightfully theirs, Dusek predicts. "I wouldn't be surprised to see double-digit drops" in the percentage of reimbursement an agency receives between current and the new PPS system, he tells Eli.

Many agencies may hire professional coders, thanks to coding's increased importance under the PPS changes, Warmack predicts. "The majority of my clients are considering placing qualified coders in a quality control position," she says. They would "review all OASIS [assessments] and assist the clinicians in making the most accurate and intelligent choices with coding assignment."

Many mom-and-pop freestanding HHAs currently use an administrative or clinical staffer with little coding training to choose diagnosis codes, Dusek observes. They're the providers most at risk of seeing big payment drops under the PPS changes, he fears.

Jump Start Your Training Plan

Regardless of who is doing your coding, they will have to bone up on the PPS changes--and don't make the mistake of waiting until the final rule comes out this fall to start training.

Waiting to train is "not an option," stresses consultant Regina McNamara with Kelsco Consulting Group in Cheshire, CT. CMS is unlikely to make significant changes to the proposed PPS refinements, so you should start ramping up employees now--especially coders.

Definitely do not wait, Zuber urges. "Get started right away." In addition to beginning training, you should start considering your operational processes and how they will need to change under the new PPS rules, she adds.

An addition: Don't forget to go over new clinical domain item M0800 on injectable medications in your training. The incoming case mix item is pretty straightforward, experts agree. It's aimed at capturing resource needs for diabetic patients on injected insulin, Dusek believes. But clinicians could use a refresher on the item, since it will help determine payment.

And don't forget to point out that PPS will cut M0610 on cognitive/neuro/emotional behaviors. (For a list of clinical domain items under the PPS refinements proposal).

Note: To order a transcript or recording of Mark Sharp's recent Eli-sponsored audioconference on the proposed PPS changes, go to http://goto.elinet work.net/go/6766 or call 1-800-874-9180.