Home Health & Hospice Week

Now’s the time to start examining your coding practices.

Most home health agencies’ chief concern under the coming Patient-Driven Groupings Model is going to be claims returned because the primary diagnosis code isn’t in one of PDGM’s 12 clinical categories. When that happens, the claim will Return to Provider.

Don’t wait until the new payment model hits to figure out if you have a problem with the unallowed codes, also sometimes called “boomerang” codes because they’ll cause claims to come right back to you.

“Agencies should question whether the codes that in PDGM will be unacceptable as primary are the best choice in HH PPS” now, offers Corinne Kuypers-Denlinger with Quality in Real Time in Floral Park, New York.

You may often get the code you need by specifying laterality and coding to the highest specificity, counsels Lisa Selman-Holman with Selman-Holman & Associates in Denton, Texas.

You should check for code conventions and application of ICD-10-CM Official Coding Guidelines, as well, suggests Joan Usher with JLU Health Record Systems in Pembroke, Massachusetts.

But remember: “The coder cannot just change the code to fit into a grouper without verifying the diagnosis with the physician,” Selman-Holman warns. And “then the face-to-face encounter documen­tation must be rechecked for the clinical reason the patient requires home care.”

And sometimes, even though a code isn’t in the PDGM grouper, it still is the best choice for PPS coding now. “So, agencies should not necessarily change their code choices,” Kuypers-Denlinger cautions.

“The challenge will be for those patients who have not had a recent surgery or injury, but are still in recovery from a resolved medical condition (such as pneumonia or sepsis),” predicts Lisa Woolery with Fazzi Associates in Northampton, Massachusetts. Why? “Resolved or ‘rule out’ conditions may not be coded as active in home care,” she says.