Home Health & Hospice Week

Code change doesn’t necessarily trigger SCIC assessment — but could be red flag.

Diagnosis coding will be occupying more of home health agencies’ focus under the Patient-Driven Groupings Model — but there will be one less coding-related requirement to worry about.

Starting Jan. 1, the principal and “other” diagnosis codes won’t have to match between a patient’s OASIS assessment and the claim for the episode, the Centers for Medicare & Medicaid Services says in a May 3 transmittal. Coding will instead switch to “claim coding,” CMS says in a related MLN Matters article.

Typically, codes for a start of care or recert episode will match the corresponding OASIS, CMS expects. But “second 30-day claims in any 60-day period will not necessarily match the OASIS assessment,” the article for CR 11272 notes.

CMS also officially lets agencies off the hook for another assessment when that occurs. “When diagnosis codes change between one 30-day claim and the next, there is no requirement for the HHA to complete another follow-up (RFA 05) assessment to ensure that diagnosis coding on the claim matches to the assessment,” the MLN Matters article says.

Watch out: “However, the HHA would be required to complete an ‘other follow-up’ (RFA 05) assessment when such a change would be considered a major decline or improvement in the patient’s health status,” cautions the National Association for Home Care & Hospice. Don’t be surprised to see that become a red flag for medical reviewers going forward.

And: A previous transmittal with PDGM instructions contained “a section titled ‘SCIC’ without any additional information,” NAHC points out in its member newsletter. “This has been removed from the Claims Processing Manual, but NAHC fully expects that CMS will insert this section in future CRs.”

Resource: A link to the new transmittal is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11272.pdf.