Home Health & Hospice Week

Diagnosis coding will be more important than ever to your bottom line.

You have a few short weeks to finish preparing for the prospective payment system refinements that take effect Jan. 1, so you'd better make the most of your time to ease the transition.

A major area for your focus in these last days should be diagnosis coding, experts agree. Under the PPS refinements, diagnosis coding plays a much bigger part in how Medicare calculates your episode reimbursement.

Caution: Often, you won't get case mix points for an episode unless a diagnosis accompanies another diagnosis or M0 item answer (see Eli's HCW, Vol. XVI, No. 35). And diagnoses in all six positions of M0230/M0240/M0246 count toward payment.

Soak up information on how the new M0246 item works, advises consultant Lisa Selman-Holman with Selman-Holman & Associates in Denton, TX. Now that PPS counts secondary diagnoses toward payment, it will be crucial for clinicians to understand how case mix codes bumped by V codes in M0240 are counted in the revised OASIS item.

"Teach the assessing clinicians the importance of collecting information about co-morbidities the pa-tient may have," Selman-Holman tells providers. Any of the diagnoses for those conditions may increase your rightful reimbursement.

Do this: Have your clinicians practice scoring numerous episodes under the new PPS rules, recommends consultant Pam Warmack with Clinic Connections in Ruston, LA. Thanks to such practice, "clinicians, especially nurses, are demonstrating a better understanding of the changes and the impact of their assessments and coding on reimbursement," Warmack reports.

Tighten Up Your Coding Specificity

Make sure you're not going to lose case mix points and hard-won reimbursement due to insufficient coding, Warmack warns. If the diagnoses you commonly use in M0230 and M0240 aren't on the newly expanded case mix list, it could be because you aren't using specific enough codes.

Example: The non-specific code for Chronic Obstructive Pulmonary Disease (496.0) isn't on the case mix list under the PPS revisions, but several more specific COPD-related conditions are: Emphysema (492), Chronic Obstructive Asthma unspecified (493.20), Chronic Obstructive Asthma with Status Asthmaticus (493.21) and Chronic Obstructive Asthma with Acute Exacerbation (493.22), Warmack points out.

"Try to be more specific and therefore you will potentially capture more co-morbidity coding points," she counsels.

Coding is so important under the new PPS methodology that consultant Betty Gordon advises all home health agencies to hire certified coders to handle it. HHAs should use certified coders because of their initial training and, more importantly, the requirement than they receive ongoing updates and education.

This is controversial advice, Gordon acknowledges. But "you can't have every nurse trying to decide on the codes," maintains Gordon, with Simione Consultants in Westborough, MA.

Don't forget: And choosing the appropriate code isn't the end of the matter. You must make sure justification for the chosen primary and secondary codes is clear in the patient's record, especially when Medicare dollars are on the line. Documentation for coding choices will become even more important under the new PPS, Gordon predicts.

Other hot spots experts urge you to address in the final days before the PPS transition include:

• Recerts. Bone up on the Centers for Medicare & Medicaid Services' complicated rules for completing OASIS assessments in the last five days of the year, suggests consultant Sharon Litwin with 5 Star Consultants in Ballwin, MO. CMS instructs agencies to use "artificial" dates in M0090 to secure the correct payment code during that time period (for details, see Eli's HCW, Vol. XVI, No. 39).

To avoid the confusion as much as possible, "run a list of patients that need recertification for episode dates beginning 12/27 to 12/31," Selman-Holman offers. "Perhaps they can be scheduled prior to the 27th."

• M0826. The revised OASIS item on therapy will now ask you exactly how many therapy visits you plan to furnish for the episode. While the claims payment system auto-corrects the final claim to include the number of therapy visits ultimately reported in the epis-ode, you still have to start out making your best estimate on how many visits that will be.

And, more importantly, you must have physicians' orders for that number, a CMS official told the recent OASIS Certificate and Competency Board annual meeting in Baltimore. Currently, many agencies answer M0825 "yes" or "no" based on their estimate, but with only a physician's order for a physical therapist's evaluation. Now if agencies have that, they would be able to put only "1" in M0826 for that one eval visit.

Result: If you use "1" for the eval, in many cases you'll receive a lower request for anticipated payment (RAP) than you deserve, Gordon notes.

Instead, agencies would do well to have the PT eval finished before completing OASIS so they can put the estimated number of visits in the OASIS form. However, timing of that may be tricky in areas that have PT staffing shortages, Gordon allows.

Before the PPS changes hit, you need to decide on your policy for answering M0826 and implement it so you can enforce it after Jan. 1, Gordon advises. "That's an operational issue that has to be resolved."

• M0110. By now you should know you'll have to check the Common Working File for episode sequence information required in new OASIS item M0110. There will be major differences in an episode's reimbursement based on whether it is an early (first or second) or later (third or later) episode under the item's definition.

But don't just rely on the CWF for your answer, Gordon urges. Because it is based on claims submitted so far, the system easily can be out of date. Be sure to find out from the referral source whether the patient has had previous home care episodes. You should also ask the patients, although their answers are less likely to be accurate, she acknowledges.

Decide before changes hit exactly who will ga-ther this information and make sure it's done, she urges.

• Software vendors. If you don't have the final release of software from your vendor yet, keep on them until you do, recommends Bob Wardwell with the Visiting Nurse Associations of America. Then immediately test and train staff based on those.

If your vendor says it can't be ready in time for Jan. 1, report them to CMS, Wardwell exhorts. "Given the late release of grouper changes, CMS bears some responsibility, particularly if it's not an isolated, single vendor problem," Wardwell judges.

Tip: Touch base with other users of the software so you can identify and work through glitches together, Wardwell offers. VNAA distributed a list of its members and their software vendors for that purpose.

• Episode management. Based on the OASIS and plan of care, project an episode's expenses and revenue, Litwin advises. That will help to identify per patient profit and loss.

Tracking this will help prevent you from being ambushed by an episode you think is going to break even or make money, but that loses money.

Key: You must update the management as the episode's frequencies and orders are revised, Litwin explains. "This will keep you from having surprises, such as 68 visits made in an episode when you thought there were to be 21," she says. "I see this all the time."

• Self-audits. To protect yourself against risk under the new system, you should audit yourself, suggests attorney Marie Berliner with Lambeth & Berliner in Austin, TX.

"Agencies should ... take a close look at their current recordkeeping, OASIS, therapy visits per episode, and other documentation and coding practices," Berliner stresses. Then they can "see where they are vulnerable and identify any excesses."

"They should try to implement changes before PPS does it for them," Berliner tells Eli.

• OASIS accuracy. Medicare payment for home care patients will hinge more than ever on accurate OASIS data under the revised PPS. If you haven't done so yet, give your staff the new OASIS forms and inservice them on the new items, Litwin says.

Some agencies waited to train on the new OASIS forms so as not to confuse their clinicians trying to fill out the current OASIS forms, providers tell Eli.

Focus in: Pay particular attention to how your clinicians are filling out the ulcer questions, Warmack urges. Diabetic, stasis and pressure ulcers are crucial.

"There is a tremendous amount of money to be lost by inaccurately defining the type of ulcer and thereby coding it incorrectly," she cautions. "Money for these ulcers is found in the ICD-9 codes, OASIS M0 items and in Non Routine Supplies."

Help: Look for free inservices from wound care product vendors about how to identify ulcer types, Warmack suggests.

• Supplies. Your supplies-related paperwork will have to get up to snuff under the new system. "Train staff on how to secure MD orders for supplies and how to document the use of supplies," Warmack advises agencies.

"Our clinicians have grown lax in this regard," she observes. "With supplies now being reimbursable, it is an area of weakness for many agencies." That advice goes doubly for episodes in the highest-paying and rare NRS category 6, which pays $551 per episode.

• Time off. It may not make you popular, but financial consultant Tom Boyd suggests you restrict time off for billers during the PPS transition. "I recommend that no billing staff be allowed time off from now until after Jan. 15, other than weekends," says Boyd, with Rohnert Park, CA-based Boyd & Nicholas.

• New payments. Once you start receiving payments under revised PPS, scrutinize them for accuracy. Providers should "watch their remits after the first of the year like eagles so they can sound the alarm ... if anything starts looking odd," Wardwell urges.

"This is not the time to assume that someone else knows a problem exists," he warns.