Home Health & Hospice Week

Your reimbursement will depend on diagnosis coding more than ever before.

With the Patient-Driven Groupings Model only six months away from implementation, now is the time to make sure you are mastering a major determining factor of PDGM reimbursement — diagnosis coding.

The role of diagnosis coding will be greatly enhanced under the new payment model that takes effect Jan. 1. “Diagnosis coding will have a much greater impact in PDGM, as the primary diagnosis assigned will determine the clinical grouping category for eligibility and reimbursement,” explains Lisa Woolery, director of coding education for Fazzi Associates in Northampton, Massachusetts.

Plus: Another secondary 24 diagnoses that home health agencies can include on the claim will contribute to a comorbidity adjustment under PDGM’s case mix system, says coding expert Joan Usher with JLU Health Record Systems in Pembroke, Massachusetts. An episode can have no adjustment, a low adjustment, or a high adjustment.

To make sure you’re ready for this major change, heed this advice from industry coding experts:

1. Up your level of coding expertise. If HHAs “are not using a coding specialist, they are already way behind the curve,” warns consultant Pam Warmack with Clinic Connections in Ruston, Louisiana. Both management and staff assigning codes should understand their full impact under PDGM.

“Accuracy and a real understanding of guidelines of coding, including the importance of getting coding information from the physician, is so very important,” stresses attorney and coding expert Lisa Selman-Holman with Selman-Holman & Associates in Denton, Texas. “Mediocre is not good enough. The standard for quality has been raised for coding,” Selman-Holman tells Eli.

“The agency’s coder should understand the new rules and regulations,” underscores Kyle Johnson with Home Health Coding Solutions in Brigham City, Utah. Coders can learn directly from the Centers for Medicare & Medicaid Services and its contractors, or many classes and webinars are available for a fee, Johnson points out.

2. Examine RTP codes. Under PDGM, “patients without a primary diagnosis that fits into a clinical grouper will not be eligible for reimbursement,” Woolery emphasizes. “CMS considers the patient with a Questionable Encounter as a primary diagnosis as not appropriate for home care.”

In the new model, “most non-specific and all symptom codes will no longer be allowed primary,” Johnson elaborates.

Resources: For a list of 30 common codes that will cause claims to Return To Provider under PDGM, see Eli’s HCW, Vol. XXVIII, No. 20.For a free list of the top 75 invalid primary codes, based on 2017 data, email editor Rebecca Johnson at rebeccaj@eliresearch.com with “Top PDGM RTP Codes” in the subject line.

CMS has not issued a list of the codes that will RTP under PDGM. CMS appears to have stopped referring to them as QE codes, and Selman-Holman calls them “boomerang” codes because they send the claim back to the HHA. To see whether a code is in one of the 12 clinical categories under PDGM, you can use CMS’s grouper tool, which has a link at www.cms.gov/center/provider-type/home-health-agency-hha-center.html.

3. Assess your current coding situation. As the next step, you should “review a sampling of active patient census to determine appropriate use of ICD-10-CM coding for primary and comorbidities,” Usher advises. You’ll be looking for a number of issues, including:

• QE/invalid/boomerang principal diagnosis codes that will return claims under PDGM.
• Full and valid comorbidity coding.
• Code accuracy, specificity, and laterality.
• Reimbursement resulting from the grouper placement, as determined in part by the primary and secondary diagnosis codes.

4. Map out your coding priorities. Running your current patient load through the grouper tool should give you an idea of what you most need to work on in the next six months. Prioritize your problem areas (see #3 above) first.

5. Focus on avoiding unallowed codes. If your testing shows a significant number of claims would get rejected under PDGM for primary diagnosis codes that aren’t in the grouper, you need to look to see what better coding you could be assigning now (see related story, this page).

6. Beef up comorbidity coding. Many agencies currently are not coding as many comorbidity codes as they can. The PDGM grouper will take as many as 24 secondary diagnoses submitted on the claim into account when making a high, low, or no adjustment to payment for the factor.

Comorbidity coding is tricky, because “documentation from referral sources does not always include evidence of other conditions,” laments Corinne Kuypers-Denlinger with Quality in Real Time in Floral Park, New York. “Agencies will need to take an interdisciplinary approach to case management to ensure all comorbid conditions are properly captured on the claim,” she suggests.

As with the primary diagnosis, HHAs must check the secondary diagnosis codes for appropriate specificity, laterality, and other valid attributes.

Watch out: “Because all the codes (up to 25) have the potential to add to the HIPPS, those codes need to be verified with the physician,” Selman-Holman advises. “Medical reviewers will concentrate at least some of their efforts on documen­tation of that verification,” she warns.

HHAs may want to pay close attention to some information from CMS on this matter, Usher cautions. “CMS says that ‘Secondary diagnoses are only to be reported if they are conditions that affect patient in terms of requiring clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring,’” according to Usher. “This language is different than the current language under PPS which states ‘potentially affect the patient’s care,’” she tells Eli.

7. Train your staff. You’ll need to sort out coding education for your staff responsible for assigning and reviewing diagnosis codes, particularly in the areas you’ve identified with your assessment.

Remember: “All codes must be coded to the highest degree appropriate in order to capture these diagnoses, or they will not impact reimbursement,” Woolery reminds providers.

And just as importantly, you’ll need to educate your “front office staff to know what is expected and needed with referral info coming in,” Johnson instructs.

One of the biggest problems when PDGM begins will be physicians sending referrals to HHAs with invalid diagnoses under the model, Johnson predicts. Your intake staff will need to learn how to request valid information up front, and query when needed for further information.

“Processes should be evaluated and tools provided to be sure adequate information for accurate diagnosis assignment is available as soon as possible from the point of referral,” Woolery emphasizes.

8. Educate referring physicians. Home care providers will need to teach their referring physicians about the new specificity requirements for codes under PDGM, Johnson expects.

You’ll need to determine how you will communicate with the physician to verify diagnosis codes, Warmack offers. “I am working with my clients to develop tools to communicate to referring physicians which diagnoses are not currently recognized and which alternatives to those diagnoses are approved,” she recounts. However, that list likely won’t be final until the 2020 final rule comes out this fall, she points out.

9. Open lines of communication. Keep in touch with your vendors — software and coding, if applicable — to learn about their preparations and make sure they’ll be ready come January, Warmack advises.

10. Stay tuned for changes. Changes related to PDGM and coding could take place in the 2020 rulemaking cycle, or via other subregulatory means.

For example: The industry is hoping to persuade CMS to add some diagnoses it sees as valid to the grouper model, Warmack notes.

Watch for the proposed and final rules, as well as transmittals or other communications from CMS, to stay on top of any PDGM changes.