Home Health & Hospice Week

Get the bottom line on how to follow the new guidance.

The new OASIS User's Manual Attachment D is turning the home care coding world upside down, with instructions on how to complete M0246 leading the list of worries.

Home health agencies fear that these new changes from the Centers for Medicare & Medi-caid Services could adversely affect payment. And CMS's guidance seems to conflict with its own coding guidance elsewhere.

In the revised chapter of the Manual, CMS issues its first official instruction on how to respond to OASIS item M0246. Where coders had previously completed this section each time a V code replaced a numerical diagnosis code, now CMS instructs you to complete it only in a very limited number of situations.

Specifically, the guidance instructs that coders should use M0246 infrequently and generally only complete it when any one of the following three conditions apply:

Condition 1:

a. The primary diagnosis (M0230) is a V code;

b. The V code displaces a numeric diagnosis that is a case mix diagnosis; and

c. The numeric case mix diagnosis is contained within one of the following three home health PPS diagnosis groups:

• Diabetes;

• Skin 1 " Traumatic wounds, burns, and post-operative complications; or

• Neuro 3 " Stroke (now corrected to Neuro 1).

Condition 2: The V code replaces a case mix diagnosis that is a resolved condition.

Condition 3: The V code replaces a fracture code.

One point of confusion fixed: Listing Neuro 3 in Condition 1(c) was an error, CMS admitted in a Jan. 26 message to providers. "The correct diagnosis group is Neuro 1 " Brain Disorders and Paralysis," CMS says in the message.

CMS will post a corrected version of the new Attachment D soon, it promises.

CMS should have included Neuro 1 because this case mix diagnosis group gets more points as primary, says Lisa Selman-Holman, consultant and principle of Selman-Holman & Associates in Den-ton, Texas.

CMS's reasoning is sound in that in all other cases other than those listed, the case mix diagnosis is already listed in M0240 and therefore will be counted if points are earned, says Selman-Holman.

The bad news is that CMS wasn't very clear, and the scenarios it includes are not good examples. "Plus the risk adjustment we were getting for non-case mix diagnoses that no longer existed by placing the diagnosis in M0246 is gone," she laments.

CMS goes on to say that if coding guidelines require a secondary diagnosis to support a primary V code diagnosis, it must be sequenced immediately following the V code in M0240.

"We're told not to select codes based on payment, but these guidelines ask us to refer to table 2A and 2B, and we are to place those codes in M0230, M0240, or M0246 based on whether they are payment codes or not," notes Jan M. McLain, medical review resource nurse specialist with Adventist Health System Home Care in Port Charlotte, Fla. Clinicians have been adding the etiology codes in M0246 for any V code in M0230/240 regardless of payment, but now they must know which diagnoses are case mix and code according to payment first, she points out.

This guidance doesn't make sense, considering CMS states to not code for payment but according to clinical condition, notes Selman-Holman.

Question: "Which CMS guidelines are we to follow when the guidance contradicts itself?" McLain wonders.

Answer: "I think it boils down to this," says Selman-Holman. Use M0246 when:

1. The V code reported in M0230 replaces a case mix diagnosis in the diabetes, Skin 1, or Neuro 1 case mix categories; or

2. The case mix diagnosis is resolved so cannot be placed in M0246; or

3. The case mix diagnosis is a fracture (traumatic or pathological) because coding guidelines restrict the fracture codes to settings providing active treatment; therefore, fracture codes cannot appear in M0230 or M0240.

Also: The secondary diagnoses, if listed in M0240 must be addressed in the plan of care. v

Note: Attachment D is posted in the "Down-loads" section at http://www.cms.hhs.gov/HomeHealthQualityInits/14_HHQIOASISUserManual.asp.

For more information on diagnosis coding, see Eli's Home Health ICD-9 Alert at http://www.elihealthcare.com/spec_health_icd-9.htm.