Home Health & Hospice Week

Can you back up the codes you're choosing for patients?

Under the prospective payment system, your diagnosis coding can make or break your episode reimbursement. But you have to make sure it will stand up to scrutiny.

Regional home health intermediary National Government Services conducted recent probe reviews on claims with psychiatric, hypertension and cerebral vascular disease diagnoses, according to a message NGS sent to providers.

Despite the different diagnosis groups, NGS found the same problem across claims--"Primary diagnosis was not the main focus for home care."

"According to OASIS guidelines the primary diagnosis (M0230) should be the chief reason for providing home care," says NGS, which was formerly United Government Services and Associated Hospital Service of Maine. "Home health providers are expected to determine the diagnosis based on the condition most relevant to the current plan of care. The primary diagnosis should represent the most acute condition and the one that requires the most intensive skilled services."

Consultant Sharon Litwin sees this problem frequently when she's reviewing records, she tells Eli.

Example: A home health agency receives a referral that says the patient has hypertension, so the clinician puts that down as the primary diagnosis, relates Litwin, with 5 Star Consultants in Ballwin, MO. But the patient's blood pressure is normal upon admission. However, the patient also has congestive heart failure and has difficulty walking and shortness of breath.

The nursing and therapy visit notes focus on the difficulty walking and the CHF. "This is then a problem upon review, as HTN is not the problem," Litwin points out. "There is no justification for the primary diagnosis."

Don't Let PPS Confuse Your Coding

Diagnosis coding can lose accuracy "when selection of the primary diagnosis is motivated by reimbursement considerations," cautions regulatory consultant Rebecca Friedman Zuber in Chicago. "While it is important not to leave money on the table, providers also must be sure they are abiding by the coverage and care planning rules when they complete their assessments."

Tip: Remember that the primary diagnosis must be the one "that is related to the preponderance of the care plan," Zuber advises. In fact, "it might not even be the most serious diagnosis the patient has."

Pitfall: Don't make the mistake of choosing a case mix diagnosis code first and "backing into" it for reimbursement reasons, warns consultant Karen Vance with BKD in Springfield, MO. The clinician or coder should base her coding choice squarely on the assessment.

Clinicians should aim to complete "the best possible comprehensive assessment," Vance exhorts. That in turn will drive a well-thought-out plan of care.

Then make sure your "defensible" documentation supports that coding choice, Vance says.

Bottom line: Defending claims against medical review denials is all about "going back to the basics," Vance stresses.

You can improve documentation by using case management, Litwin suggests. The main disciplines involved in the case and conducting assessments--often an RN and physical therapist--should collaborate on the care plan to make sure it has "the proper primary diagnosis for the focus of the episode, and the proper orders including frequency and duration," she says.

Take the time to wait for the team to agree on the coding and sequencing, Vance offers. "Wait for the interdisciplinary coordination--however it happens in their agency," she says. "It may take a few days more to drop the RAP, but it would be more accurate data and fewer corrections would have to be submitted later."

Don't overlook: Once the plan of care is set, it's vital for you to communicate the plan to the other staff who will see the patient so they can document accordingly.

"In many chart reviews, I see this is the breakdown," Litwin relates. "It is obvious that [the visit staff] have not ... read the plan of care, because they document different items than are on the 485."

Note: To receive a free copy of NGS' article, email editor Rebecca Johnson at rebeccaj@eliresearch.com with "NGS Medical Review Article" in the subject line.

For more information and details on diagnosis coding in home care, see Eli's Home Health ICD-9 Alert at www.elihealthcare.com/spec_health_icd-9.htm.