Home Health & Hospice Week

A big shift in coding could prove CMS right that agencies were gaming.

Now that it's the new year, you can no longer earn case mix points for two common hypertension codes. But that doesn't necessarily mean your agency has to take a reimbursement hit. Other comorbidities and more specific coding may soften the blow.

In the prospective payment system final rule for 2012, the Centers for Medicare & Medicaid Services said, "Beginning with M0090 dates of Jan-uary 1, 2012, 401.1 Benign essential hypertension codes and 401.9 Unspecified essential hypertension are removed from the HH PPS case-mix system. Specifically, 401.1 and 401.9 diagnosis codes will no longer result in additional points when computing the HIPPS codes."

Lack Of Documentation Led To  Case Mix Change

CMS eliminated case mix points for codes 401.1 and 401.9 because agencies were using them inappropriately, says consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. Home health agencies often used these HTN case mix codes as a primary diagnosis at start of care and in the second, third, or subsequent recertifications as a means to both garner three case mix points and/or to keep the patient on services, Laff says.

Problem: When hypertension is the primary diagnosis, once your patient's blood pressure is stable and you've provided teaching on any new hypertension medication, it's expected you'll work toward discharge, says coding expert Jennifer Warfield with PPS Plus Software in Biloxi, Miss.

And during medical review, there is often no documentation to support the need for skilled services related to the hypertension diagnosis for these patients, Laff says.

CMS statistics show that patients with hypertension were getting fewer visits than those without hypertension, which contradicts the reason for case mix status, notes attorney and coding expert Lisa Selman-Holman of Selman-Holman & Asso-ciates and CoDR -- Coding Done Right in Denton, Texas. Diagnoses with case mix status indicate the patient needs more care because of that diagnosis.

Don't change the codes you use for hypertension unless you have been listing one of the 401.x codes in error, says Selman-Holman. "Changing the codes just to get points is upcoding and we certainly do not want to prove CMS correct about case mix creep. You can be sure that they will be watching for trends in hypertension coding as a result of the case mix change," she says.

You can continue to code hypertension if it is a diagnosis that your agency will be managing and addressing in the plan of care and visit notes, Laff says. Just make sure that you are coding correctly and that you continue to include hypertension where it is appropriate when the patient actually has HTN as a comorbidity, she says.

See The Silver Lining

The loss of case mix points for hypertension diagnoses may seem like a blow at first, but don't despair, says Selman-Holman. "Even if you don't earn points with the hypertension codes, think how many of your patients with 401 codes also have codes from the 414.x category (Coronary atherosclerosis and chronic ischemia), 410.x (Acute myocardial infarction) and 428.x (Heart failure). Those codes are case mix, too, so you will not be losing any points," Selman-Holman points out.