Home Health & Hospice Week

Warning: Medicare will be watching how you use the newly included dysphagia codes.

If you’ve been trying to figure out how you’re going to get around coding dysphagia under the incoming Patient-Driven Groupings Model, you can relax.

Why? In the 2020 home health final rule, the Centers for Medicare & Medicaid Services announces it will allow a group of dysphagia codes to count toward case mix (see box, this page).

Remember: “There are four steps in the grouping of a patient into the PDGM Home Health Resource Group (HHRG), which establishes the case mix weight and eventual payment,” Healthcare Provider Solutions’ Melinda Gaboury says on the firm’s blog. “ICD-10 coding makes up 50 percent of that process” — the principal diagnosis reported on the claim determines the clinical group (step 2) and up to 25 secondary diagnoses reported on the claim determine the comorbidity adjustment (step 4).

The rule spends a lot of time explaining why symptom codes in the R category cannot be the primary diagnoses under PDGM. But then it details why dysphagia codes are the exception.

For the 28,000 or so 30-day periods where R13.10 (Dysphagia, unspecified) was reported in 2018, “we found that while there were incidences where there were other reported diagnoses which could explain the reason for the dysphagia, more often than not, there was no clear clinical picture of the possible etiology where a different reported principal diagnosis would signal the need for therapy,” CMS says.

Commenters on the July proposed rule told CMS “while there are diagnosis codes for dysphagia resulting from a cerebrovascular event (for example, stroke) and others resulting from somatoform disorders (for example, psychogenic dysphagia), there are very few disease-specific diagnosis codes to identify associated dysphagia (for example, dysphagia resulting from throat cancer treatment),” the rule says.

The result: “The majority of codes to describe dysphagia are the R13 codes,” CMS acknowledges. “Commenters stated that those patients with dysphagia due to etiologies not associated with cerebrovascular events would most often require speech-language pathology therapy if the primary reason for home health services is for the dysphagia.”

Bottom line: “Given the current lack of other definitive diagnoses to describe certain forms of dysphagia, we agree that the R-codes to describe dysphagia would be acceptable for reporting the primary reason for home health services,” CMS concludes in adding the new codes. They will count toward the Neuro Rehab clinical group.

CMS doesn’t appear too bothered about whether the dysphagia is actually related to a neuro problem. Even if it’s not, “the intensity of speech-language pathology therapy would be similar to those suffering from dysphagia resulting from a neurological condition,” the final rule indicates.

While CMS stands firm on most of PDGM’s structure in the 2020 final rule, coding expert Joan Usher says she did expect the agency to implement this change. Of all the codes commenters asked CMS to include in the case mix system, “this is the only one where agencies serve a lot of patients with no underlying causes,” says Usher, with JLU Health Record Systems in Pembroke, Massachusetts.

“This should be very helpful” to home care providers, Usher tells Eli.

CMS does warn in the rule that it will keep an eye on how home health agencies utilize these codes. “We will monitor the use of these dysphagia R-codes to determine their impact on resources utilization and whether any future changes would be warranted,” the agency says in the final rule.

Note: The final rule is at www.govinfo.gov/content/pkg/FR-2019-11-08/pdf/2019-24026.pdf.