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 [...]