Home Health & Hospice Week

Medical reviewers are getting serious about coding validity as PPS changes take effect.

If you think the intermediaries are going to give you an easy time on diagnosis and OASIS coding as you ease into the PPS transition, think again.

Regional home health intermediary Associated Hospital Services already has denied a high number of claims in recent probes because the "primary diagnosis was not the main focus for home care," it reports on its Web site in a probe result summary.

"According to OASIS guidelines the primary diagnosis (M0230) should be the chief reason for providing home care," AHS tells home health agencies. "Home health providers are expected to determine the diagnosis based on the condition most relevant to the current plan of care."

Tip: The primary diagnosis should be for the most acute condition, AHS instructs. It should also require the most intensive skilled services.

And "the primary diagnosis should match the OASIS M0230 diagnosis code, the Plan of Care and the medical record," AHS reminds providers.

Pitfall: Under PPS revisions if you fail to sequence your codes correctly, you stand to lose major case mix points in all six positions of OASIS coding items M0230/M0240/M0246. Do Your Records Support M0 Item Responses? The probes also commonly downcoded claims based on OASIS responses reviewers couldn't validate, AHS reports.

"The majority of downcodes were in the Clinical Severity Domain," the intermediary reveals. "The medical record documentation does not support the OASIS M0 item response."

For example: A common culprit for OASIS downcoding is the M0 item on pain interfering with activity (M0420). If the clinician marks response #2 (daily, but not constantly), documentation must show evidence of that pain.

In a typical case, "there is no mention of pain, medication adjustments and response in the POC or the medical record," AHS says. "We would be unable to validate that the patient had pain 'daily, but not constant.'" Other hot spots: Other reasons for frequent denials or downcodes included skilled services being medically unnecessary and the ever-popular non-re-sponse to the additional development request (ADR).

Note: The probe summary is at www.ahsmedicare.com/files/documents/ngs_121107home.htm.