Home Health & Hospice Week

Is incorrect diagnosis coding costing you $750 per episode? 

Home health agencies whose favorite coding letter isn't "V" could be losing big bucks now that new diagnosis coding rules are in effect.

Both V and E ICD-9 diagnosis codes became required Oct. 1, thanks to the Health Insurance Portability and Accountability Act.

When a V code replaces a so-called case-mix or payment code in M0230 on the OASIS assessment, agencies could see major reimbursement losses unless they know to put the case-mix code in newly created OASIS item M0245 (see pdf of Eli's HCW, Vol. XII, No. 30, p. 234).

"This is going to be a disaster," consultant Melinda Gaboury of Nashville, TN-based Home-care Provider Solutions predicted on the eve of V code implementation. "It's going to be horrible."

"The use of V and E codes and M0245 is going to throw many, many agencies for a major loop," agrees consultant Pam Warmack with Rus-ton, LA-based Clinic Connections.

For example, if agencies now use a V code for physical therapy to replace abnormality of gait (781.2), and fail to enter abnormality of gait in M0245, they could be out about $750, depending on how they fill out the rest of the OASIS assessment. "Losses are going to be huge," Gaboury tells Eli.

V code problems are going to fall into these three categories, experts say:

1. Incorrect coding. Nurses have "incredible difficulty ... in applying the V and E codes," Warmack relates. HHA staff must figure out when ICD-9 coding guidelines require them to use V codes as primary diagnoses.

Faulty coding advice gleaned from listservs or outdated coding educational sessions isn't helping HHAs figure out how to use V codes correctly, Gaboury laments.

2. OASIS. Even if staff can get V coding techniques down pat, they still have to understand how to put a former primary diagnosis that is also a case-mix code into M0245 to obtain the correct reimbursement for the patient. Unless they put the diagnosis code into M0245, agencies will fail to assign a higher-paying home health resource group and HIPPS code to the patient for certain diabetes, orthopedic and neurological diagnoses.

3. Billing. Even if staff master the onerous tasks of assigning a V code as primary diagnosis correctly AND entering the bumped case-mix code in M0245, there remains one big obstacle: how to bill correctly for the patient. "Agency personnel must figure out how to ensure case-mix diagnoses make it to the UB92 and the Plan of Care in addition to M0245," Warmack warns.

HHAs should remember that the diagnosis from M0245 does not go onto the home health claim, advises consultant M. Aaron Little with BKD in Springfield, MO. The diagnosis is used to come up with the patient's HHRG and resulting HIPPS code, and then the HIPPS code goes on the claim. "M0245 is for OASIS reporting/case-mix calculation purposes, rather than for billing purposes," Little explains.

The Centers for Medicare & Medicaid Services does, however, expect to see the M0245 diagnosis show up on the patient's plan of care, it made clear in a question-and-answer document it released last month, based on an Aug. 20 teleconference with OASIS software vendors. It's up to agencies where they enter it on the POC.

Tip: You don't have to cancel and rebill an open episode's request for anticipated payment that was submitted prior to Oct. 1, even if the RAP doesn't use post-Oct. 1 V code procedures, Little reminds agencies. However, you should make sure the final claim for the episode uses the same diagnosis codes as the original RAP, even though they're now "noncompliant," he advises.

HHAs that have done little V code training are likely to see plummeting reimbursement rates for many patients, Gaboury predicts. But for many agencies, "it will be too late" before they realize their mistakes. "It's going to be a fiasco."

Such agencies will find themselves in the middle of a cash flow crisis if they don't turn around their V coding processes as soon as possible, she predicts.

Even agencies that have done lots of advance preparation will find that staffers responsible for coding will have many questions, Warmack forecasts. They should be sure to have their "go-to" coding person available for consultation when questions arise.