Home Health & Hospice Week

Under scrutiny: In the HH PPS 2011 final rule, the Centers for Medicare & Medicaid said it's studying use of M1024 (Payment diagnoses) for further modification. Certain diagnoses currently encoded in M1024 should not be reported as primary or secondary diagnoses and cannot be reported on the bill, CMS noted.

CMS went on to say that it is in the process of analyzing options to map diagnoses currently reported in M1024 to diagnoses that are reportable under ICD-9-CM guidelines as primary and secondary diagnoses in the home health setting. "We have been encouraged with our ability to map some trauma codes reported in M1024 to after-care codes, which are reportable as primary and secondary diagnoses ... However, additional analysis and mapping are needed to fully resolve this challenge," CMS said.

In Appendix D of the OASIS-C Guidance Manual, CMS instructs home health agencies that they may optionally complete M1024 when a V code replaces a case mix diagnosis that would be inappropriate to report in M1022. However, there's another layer of complexity to this instruction: CMS allows HHAs to list a code in M1024 at the primary level forcase mix payment calculation that has already been reported in M1022 in three special situations.

If the principal diagnosis (M1020) is a V code and the V code displaces a case mix diagnosis that is contained within one of three designated home health PPS diagnosis groups it would be OK to report the code in 1024 at the primary level even if the code has already been reported in M1022. The three designated home health PPS diagnosis groups are Diabetes; Skin 1 -- Traumatic wounds, burns, and post-operative complications; or Neuro 1 -- Brain disorders and paralysis.

As it stands currently, M1024 is not being used just to recoup payment lost by using V codes, but also to ensure correct payment, says coding expert Sparkle Sparks with Redmond, Wash.-based OASIS Answers.

Appendix D also recommends using M1024 to avoid losing case mix points in the case of a resolved condition (example: cholecystitis) and fractures (because of official coding guidelines that restrict the acute fracture codes to the emergency department, physician, and hospital).

Key: M1024 is a "made up" payment concept, Sparks says. As a result, M1024 doesn't follow ICD-9 coding guidelines and often leaves coders confused. "M1024 isn't a coding concept," she says. When the original PPS debuted in 2000, it did not include V codes at all, so CMS had to come up with a fix allowing agencies to continue to legitimately earn points when the diagnosis had to be replaced by a V code, says attorney and coding expert Lisa Selman-Holman of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. That fix was M0245.

M0245 has evolved with each change to PPS and is currently M1024, Selman-Holman says. In order to better understand how to answer this OASIS question, look to the guidance in Chapter 3 and Appendix D of the OASIS-C Guidance Manual and at any relevant CMS Q&As.