Home Health & Hospice Week

Codes slated for case mix removal are needed.

Home health agencies are keeping their eyes peeled to see which diagnosis codes CMS axes in the 2014 HHPPS final rule expected next month.

Keep These Category 1 Codes

Commenters on the rule proposed in July would like to see these codes from category 1 re-tained for case mix:

• GI ulcers and gastritis (531-535)
• Diverticulitis/diverticulosis (562)
• Hemorrhage of GI tract (578.9)

Patients for whom these codes apply "re-quire skilled services related to education on disease management, new medication management, and diet," insists the Texas Association for Home Care & Hospice in its comment letter on the proposed rule. "These patients are always at risk for exacerbation and complications, particularly for several days after discharge from an acute inpatient stay. Liter-ature indicates that even a minor upper GI bleed requires monitoring by a responsible adult once the patient returns home," and the bleed can take up to 10 days to resolve.

These patients also require coordination of care with the physician to monitor lab work, symptom management, home infusion therapy for hydration, and wound and drain care, adds Pat West of Pioneer Home Health in Bishop, Calif.

Patients who have surgery for diverticulosis or diverticulitis may have the area of the bowel operated on clear, but have other areas that still have active disease process, says Judy Adams with Adams Home Care Consulting in Asheville, N.C.

Agencies can’t just change codes, TAHCH adds. "Home health agencies must code what the physician documents," says the trade group. For example, "it is not appropriate to change the code to ‘without hemorrhage’ just because the patient returned home."

Another code commenters want to keep is:

• Post-hemorrhagic anemia (285.1)

Post-operative anemias due to significant blood loss during surgery or just prior to surgery are pretty common in home health, Adams says. "The anemia is still present on return home and home health nurses teach about the condition, signs and symptoms to look for and monitor for any continued bleeding, as well as educate the patient about what should be reported and nutritional steps to treat the anemia while it is resolving." Even patients who have received blood transfusions in the inpatient setting due to these blood loss anemias do not return to normal right away; they need continued monitoring and evaluation, she says.

More codes commenters want to stay in case mix calculations are:

• Peritonitis (567.21)
• Peritoneal Abscess (567.22)
• Liver Abscess (572.0)
• Acute pancreatitis (577.0)

These conditions often aren’t entirely resolved upon admission to home care, notes the National Association for Home Care & Hospice in its comment letter. These patients may be very costly for reasons ranging from IV antibiotics, TPN, drains, pain management, and more.

Patients with abscesses may undergo incision and drainage and attempts to clean up these wounds, Adams tells Eli. But they often return home with the abscess still present and being drained with orders for the home health nurses to do packing and wound dressings.

"Home health agencies must receive adequate reimbursement to care for these complex patients in order to keep them at home and reduce unnecessary and expensive re-hospitalizations," West notes.

The codes above, plus many others, "can create wounds that would likely not be completely healed in the acute care setting," the Wound Ostomy and Continence Nurses Society says in its letter. "While we agree that all of these conditions are acute diagnoses, our patients do go home with ongoing treatment for these items in ways of ostomy and tubes, as well as post-operative wounds that still require treatment. If these codes are eliminated then there may not be access to utilizing the diagnostic reason for the tube, ostomy or wound."

Keep These Category 2 Codes

Commenters on the rule would like to see these codes from category 2 retained for case mix:

• Esophageal reflux (530.81)
• Restless leg syndrome (333.94)

These conditions "can impact the home health plan of care and may require additional resources related to poor symptom control and /or medication management that requires skilled assessment and education," NAHC insists. "It is not uncommon for patients with esophageal reflux disease to vary their compliance with medication and diet regimens due to reflux exacerbations and pain."

Restless leg syndrome patients can be treated in home health through monitoring new medications, teaching about the condition and the medications being used, and monitoring and evaluating the effectiveness of new treatments, Adams says.

And agencies should report:

• Sickle cell trait (282.5)

This condition is a serious risk factor, Ad-ams maintains. HHAs that do not identify this and educate patients regarding the disease process would be providing very poor quality care, she says.