Home Health & Hospice Week

CMS rebuffs suggestions to add codes to higher-paying MS Rehab, Wound clinical groups.

If you feel like PDGM is leaving some worthy codes totally out of the case mix system, you’re not alone. Multiple commenters on July’s proposed 2020 payment rule urged the Centers For Medicare & Medicaid Services to add diagnosis codes to the Patient-Driven Groupings Model case mix methodology or change case mix categories, but CMS says “yes” in only a few cases (see story, p. 343).

The agency’s more common answer is “no.” CMS upholds excluding these codes from PDGM:

• M62.838 (Other muscle spasm) shouldn’t go in the MS Rehab group, CMS tells commenters on the 2020 final rule. “This diagnosis code does not provide sufficient information to substantiate the need for home health services,” CMS maintains in the rule.
• M06.9 (Rheumatoid Arthritis, unspecified) should not go into the MS Rehab group either, CMS says. “If the patient has multiple joints affected, M06.89 (Other specified RA, multiple sites) would be the appropriate code to report,” according to the final rule.
• M54.5 (Low back pain) should not factor in PDGM payments, CMS says. “Given the vagueness of this … code, we question whether this would necessitate the need for home health services absent more information.”

And CMS shoots down requests for case mix shifts for these codes:

• E11.51 (Type 2 diabetes mellitus with diabetic peripheral angiopathy w/o gangrene) shouldn’t move from the MMTA-Endocrine to the Wound group, CMS responds. “These two conditions are not synonymous,” CMS says in response to commenters’ argument that venous insufficiency in a patient with diabetes is assumed to be a diabetic angiopathy.
• The T84.5, T84.6, and T84.7 series of codes for infection and inflammatory reactions to joint prostheses should stay in the MMTA-Infectious Disease/Neoplasms/Blood-forming Diseases group, not move to the Wound group, CMS says. “These listed diagnosis codes could be present in the absence of an open wound,” the agency maintains. “There are other codes that should be reported in the event of a wound that results from a complication of an internal joint prosthesis,” such as T131XD.
• T87.41-T87.43 for infection of amputation stumps should stay in the MMTA-Infectious Disease/Neoplasms/Blood-forming Diseases group, not move to the Wound group. Again, there can be an infection without an open wound, CMS says. When there is an open wound, “the code for the wound would be reported as principal,” the agency adds.
• CMS also turns down a recommendation to move a code out of the Wound group — Z48.01 (Encounter for change or removal of surgical wound dressing). Since “aftercare codes are generally first-listed to explain the specific reason for the encounter” and there are no sequencing requirements for them, the code should stay in the Wound group, CMS maintains.