Home Health & Hospice Week

V codes are just one of many sequencing concerns that could cost you precious dollars.

Coding experts agree--the trickiest thing about coding under the revised prospective payment system is sequencing. You can choose all the right ICD-9 codes, but if you don't know how to put them in the right order, you won't get the case mix points you deserve.

New payment question M0246 has six slots and "they are all potential case mix slots," says Las Vegas-based consultant and certified coder Sharon Molinari.

Hurdle: Many people are still confused by M0245, and M0246 is six times more confusing, maintains Molinari.

If you place a V code in the primary or any of the secondary diagnosis positions in M0230 and M0240--and the V code replaces a case mix diagnosis--you have an opportunity to gain case mix points for the episode.

But knowing when to report a V code and where to list it can be confusing. To help make your decision, try asking how important the V code is, suggests consultant and certified coder Judy Adams with LarsonAllen in Charlotte, NC. If the V code is important and it replaces a numerical case mix code, put it in the top six OASIS diagnosis slots, she says. If it's not as important, then code it at the bottom of the list.

Most V codes are reason for encounter codes and do not give a clue to the underlying condition, says attorney and certified coder Lisa Selman-Holman, principal of Selman-Holman & Associates in Denton, TX. It's best to list the condition codes prior to reporting V codes such as V58.31 (Encounter for change or removal of surgical wound dressing) or V58.83 (Encounter for therapeutic drug monitoring), she says.

Tip: You'll generally sequence aftercare following surgery codes such as V58.4x (Other aftercare following surgery) or V58.7x (Aftercare following surgery to specified body systems, not elsewhere classified) as primary if the patient had surgery, there are no complications and aftercare is the focus of care, says Selman-Holman.

But you should ask first if there is a complication because an acute condition trumps a V code, says Selman-Holman. Coders should also consider whether another diagnosis is really the reason for home care even though your agency is also providing aftercare.

For example: Your patient had gall bladder surgery, but while in the hospital her hypertension exacerbated and she contracted an upper respiratory infection causing her chronic bronchitis to exacerbate. While you may be providing aftercare following surgery, the aftercare is not the focus of care for this patient, says Selman-Holman. Instead, you would list:

• M0230a: 401.9 (Essential hypertension, un-specified);
• M0240b: 491.22 (Obstructive chronic bronchitis; with acute bronchitis);
• M0240c: V58.75 (Aftercare following surgery of the teeth, oral cavity, and digestive system, NEC); and
• M0246c(3): 575.10 (Cholecystitis, NOS).

Bonus: You can earn case mix points for hy-pertension, chronic bronchitis and cholecystitis in this scenario, says Selman-Holman.

Determine Focus Of Care

The key to knowing when a V code is important is understanding how to determine the focus of care. Look to the clinician's assessment and the information you have from the hospital or physician. Then, use that to determine the focus of care and the secondary diagnoses which may impact the care, says Molinari.

For example: Your patient was admitted for home care following an open reduction with internal fixation (ORIF) for a hip fracture after falling at home. He also has cystitis due to a Foley catheter that is still in place for urinary retention. Nursing is ordered for post-op and genitourinary assessment, teaching and staple removal. Physical therapy will provide gait training.

In this multi-disciplinary case, the primary focus of care for both nursing and therapy is aftercare for the healing traumatic hip fracture, says Molinari. So V54.13 (Aftercare for healing traumatic fracture of hip) is the principal diagnosis you'll list in M0230.

Next, you would code 781.2 (Abnormality of gait) in M0240b. Follow this with 996.64 (Infection due to indwelling urinary catheter), which instructs you to use an additional code to identify the infection, 595.9 (Cystitis, unspecified).

Also, list 788.20 (Retention of urine) and V58.32 (Encounter for removal of staples), Molinari says. In addition, you may add the E code for the fall at home (E849.0), she says. This is optional but may help in determining liability. Do not code V53.6 (Fitting and adjustment of urinary catheter) due to the urinary complication.

Because the V code listed in M0230 replaces case mix diagnosis 820.8 (Fracture of neck of femur; unspecified part of neck of femur, closed), you should place 820.8 in M0246 Column 3 for the case mix points, Molinari says. Leave M0246 Column 4 blank because this column is used only in mandatory multiple coding situations, such as manifestations, she says.

However, 820.8 is in the Ortho 1 diagnosis group and will garner only two points if the patient is in the first or second episode with fewer than 13 therapy visits and the patient has a pressure ulcer. Or, a diagnosis of 820.8 could earn five points in the first or second episode with low (0-13) or high (14+) therapy visits and if the patient requires IV therapy, Molinari says.

The example case earns no clinical case mix points for the primary diagnosis because the patient has neither a pressure ulcer nor requires IV therapy, Molinari says. Code 781.2 is also a case mix diagnosis in its own diagnosis group but only gains points when the patient also has a pressure ulcer and V58.32 replaces the Ortho 1 case mix code, 820.8. Thus, there are no case mix points for these diagnoses either.

Points in this diagnosis group will be difficult to obtain, Molinari says.

Don't Forget Co-Morbidities

Co-morbidities play a big role under the revised PPS, Molinari says. If the patient has diabetes or hypertension he might be stable but you still need to report these conditions because they may impact the patient's care, she says. For example, diabetes could slow the patient's healing.

Blindness, congestive heart failure (CHF), and coronary artery disease (CAD), co-morbidities that you always should code, are now case mix diagnoses that need to be in the top six positions to get case mix points, Molinari says.

Keep An Eye On Non-Routine Supplies

Sequencing doesn't impact only the clinical portion of the home health resource group (HHRG). It also impacts non-routine supply (NRS) reimbursement as well as an agency's risk adjustment, points out coding specialist Tricia Twombly with Foundation Management Services in Denton, TX.

For example: Because of a correction made to the PPS final rule in Tables 10A and 10B, the only time an agency will be able to count NRS points for taking care of a diabetic ulcer is when 250.8x (Diabetes with other specified manifestations) is listed in M0230 followed by the ulcer code, says Twombly. If an agency lists the diabetes and ulcer codes in M0240 instead of M0230/M0240b, they won't garner any supply reimbursement. However, the sequencing would depend on whether the diabetic ulcer is the focus of care or not, says Molinari.

Don't miss: If diabetic neuropathy caused the ulcer, the diabetes code changes to 250.6x (Diabetes with neurological manifestations) and PPS awards no NRS points, says Twombly.

With all of the PPS changes and challenges, remember that quality of care and compliance, rather than reimbursement, should be your focus, Molinari says. A great assessment along with OASIS and coding accuracy will ensure that your agency will receive the reimbursement it's entitled to, she says.

Note: For more coding information like this, see Eli's Home Health ICD-9 Alert at www.elihealthcare.com/spec_health_icd-9.htm or by calling 1-800-874-9180.