Home Health & Hospice Week

Make sure your staff know how to query physicians for coding specifics.

An inaccurate diagnosis code can mean getting underpaid by hundreds or even thousands of dollars under the Patient-Driven Groupings Model, or having cash flow delayed for weeks. Home health agencies should make sure coding is correct up front.

PDGM billing, as well as care planning, rely on valid primary and secondary diagnosis codes being assigned to patients. And under PDGM, many of the most commonly used codes are now designated as “Unaccepted Diagnoses” and will result in a claim being Returned To Provider (RTP’d).

“Intake staff need to be very familiar with unaccepted codes for primary diagnosis, so that prior to accepting a patient referral, it is clear that there is an appropriate underlying diagnosis that the physician approves,” advises the Home Health Certificate Course from the professional coding association AAPC.

When physicians furnish a diagnosis that is unaccepted under PDGM, or otherwise seems inaccurate for the patient, HHAs “should query the certifying physician who is responsible for establishing the home health plan of care,” instructs the forthcoming AAPC Course authored by consultant Sharon Litwin with 5 Star Consultants in Camden, Missouri.

Many agencies haven’t used the query process much — if at all — before, Harder observes. Implementing the process will take precious time that providers can ill afford to spare.

Do this: Query the physician/referral source for specific disease information and the underlying cause of a symptom, the AAPC Course says.

Remember: “If there is no acceptable diagnosis under PDGM as the primary diagnosis, then the HHA should not admit the patient,” the AAPC Course stresses. “Having intake involved at the front end is critical.”

Some providers’ coding capabilities are hampered by the fact that they have neither a certified coder on staff nor have outsourced their coding needs, notes Kyle Johnson, owner and director of coding operations with Home Health Coding Solutions in Brigham City, Utah. Those agencies often fail to understand the “PDGM coding change and how the primary code affects the entire revenue stream, as well as codes that are no longer allowed primary,” Johnson observes.

Focus On Coding For 2nd Billing Periods

The Centers for Medicare & Medicaid Services has made clear that it’s OK for HHAs to have a different primary diagnosis for a second 30-day billing period, even when it won’t match the primary diagnosis code on the corresponding OASIS assessment for the 60-day episode (see Eli’s HCW, Vol. XXVIII, No. 29).

But many agencies have policies and procedures that are lagging behind that rule. “The process for determining the 30-day primary diagnosis should be a big focus” right now, insists consultant J’non Griffin, owner of Home Health Solutions in Carbon Hill, Alabama. “So many agencies haven’t implemented that process,” which is a problem due to “all the departments it will affect and what the implications are if they change the focus [of care], but don’t change the clinical grouping on the review process.”