Home Health & Hospice Week

Lots of new coding options available under proposed PPS refinements.

Case mix diagnosis groups are getting an extreme makeover. Get ready to toss your old cheat sheets and give your coding practices an update.

The Centers for Medicare & Medicaid Services' proposed rule on the prospective payment system released April 27 not only expands diagnoses in the existing case mix diagnosis groups, it more multiplies the number of groups five-fold.

Instead of the current four case mix diagnosis groups (neurological, orthopedic, diabetes and burns and trauma), the rule proposes to expand and break diagnoses out into 20 new groups.

The changes "are definitely more reflective of home health services than the original four case mix groups," says consultant Judy Adams with Larson-Allen in Charlotte, NC. "Now, more than ever, coders will need to pay close attention to sequencing diagnoses."

One benefit of the expanded case mix groups will be less pressure to use one of the diagnoses in the original limited group, Adams says.

Getting serious: The new case mix groups will reduce gaming and upcoding, predicts consultant Lisa Selman-Holman of Selman-Holman & Associates in Denton, TX. Coders who make their diagnosis code selections based on the focus of the care and also code the co-morbidities will get the number of points intended she says.

It will be very difficult to selectively choose codes to get the best reimbursement, Selman-Holman says. This is because there are now four equations, which determine reimbursement, depending on the number of therapy visits the patient will receive and which episode (early or late) the patient is in. One coding combination in the first episode may get you a certain number of points and the same coding combo in the third episode may not get you any points, she says.

Secondary Diagnoses Take Center Stage

In developing the new groups, CMS added secondary diagnoses to the case mix system. This change in calculation is an effort to account for the cost-increasing effects of comorbidities, CMS says.

However, assigning scores to both primary and secondary diagnoses could lead to redundancies, so CMS proposes to recognize only the primary diagnosis in episodes where both primary and secondary diagnoses from the same diagnosis group are listed.

"Recognizing the primary diagnosis, but not the secondary diagnosis in the same diagnosis group, seems like a reasonable approach to using the variable system," says Adams. When used correctly, the new system should recognize the impact on case mix for key diagnoses, yet not overstate the impact when there are multiple diagnoses from the same group, she says.

Bonus: Most coders know there are conditions they should always code because these conditions may affect the care, even if they are not the focus of care, Selman-Holman says. Some of these are the same conditions that CMS has chosen to contribute to the case mix as "other diagnoses."

For example: Diabetes will gain you points as a primary diagnosis. But because it also affects other conditions, diabetes will also gain you points as a secondary diagnosis.

Say Goodbye To M0245

As a result of these changes, M0245 will no longer be part of the diagnosis coding process. Assigning case mix points for both primary and secondary diagnoses requires that OASIS allow for reporting V codes in place of a case mix diagnosis in secondary positions--not just in the primary diagnosis spot as with M0245 now. To facilitate this change, CMS proposes replacing M0245 with a new OASIS item.

In the proposed changes and the draft revised OASIS tool, M0246 replaces M0245. The new M0 item changes format to recognize the complexity of the new case mix system, which incorporates four models and the expanded use of diagnoses, Adams says.

Out with the old: M0246 will serve the same purpose as M0245 but will allow you to list a case mix or payment diagnosis in those situations when you have used a V code in place of a case mix diagnosis code in either a primary or secondary position.

Waste no time: CMS' projected im-plementation date for these PPS refinements is Jan. 1, which means it will affect recertification assessments on or after Dec. 27. But agencies will have to wait until CMS issues the PPS refinements final rule to receive the final word on the changes. 

That short window of time to prepare will cause a lot of trouble for more than just coders, says Grand Rapids, MI-based consultant Arlene Maxim with Healthcare Management Consultants. Software and IT vendors will have a huge challenge to make changes in time for the rule's projected implementation, experts predict. 

Note: For more on how PPS changes will impact your coding, see Eli's Home Health ICD-9 Alert at www.elihealthcare.com/spec_health_icd-9.htm or by calling 1-800-874-9180.