Home Health & Hospice Week

Demise of GERD comes as no surprise.

While some of the 170 diagnosis codes CMS plans to cut from case mix consideration make sense, others are baffling home health agencies.

HHAs treat many diagnoses on CMS’s proposed list, says coding expert Judy Adams with Adams Home Care Consulting in Asheville, N.C. It appears the Centers for Medicare & Medicaid Services chose certain words to cue off of in making the cuts, but the current ICD-9-CM codes available do not offer other alternatives for reporting these types of conditions, she says.

For example: In its proposed rule published in the July 3 Federal Register, CMS proposes cutting several chronic ulcer codes in the 531.x (Gastric ulcer) category (see related story, p. 283). With codes like 531.40 (Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction), "CMS obviously considers the word hemorrhage as ‘too acute’ for home health," Adams tells Eli.

But while the patient is not necessarily hemorrhaging at the time he is released to home health, he may still be bleeding. Or the home health agency may need to monitor and evaluate for any new bleeding such as gastric, peptic, duodenal, gastrojejunal and esophageal ulcers, she says.

"A patient who is actively hemorrhaging would be referred to the ER ... but, there are no codes that describe just ‘bleeding’ and this diagnosis continues until the condition is gone," Adams says.

"The removal of all of these diagnoses appears to be primarily motivated by another way to reduce reimbursement to home health care without true consideration of diagnoses that are treated in the home health setting," Adams laments. "True, these are not part of the top 20 percent of home health diagnoses, but is that enough reason to say these codes can no longer earn case mix points?"

Over and inappropriate use of the case mix code 530.81 for GERD likely led to its planned removal from the list. When the medical record does not clearly identify why the condition is a problem for the patient and the plan of care does not show any intervention related to treating or controlling GERD, it’s inappropriate to code for it. An HHS Office of Inspector General March 2012 report particularly used GERD as an example of frequent inappropriate coding, Adams points out. "Removing that code was only a matter of time."

In addition to providing follow up care for patients with many of the diagnoses CMS plans to demote from case mix status, home health agencies also care for patients who have received some initial treatment in an acute care setting but still have the condition at discharge, Adams says. Plus, some patients are not surgical candidates and may not be able to tolerate or agree to surgical correction of these chronic problems. So again home health is treating the patient in the community, she says.

Do this: Don’t stop reporting these codes when appropriate. For data accuracy, "HHAs need to continue using these codes where they are appropriate to the patient situation even though they will no longer gain case mix points," Adams says.

Bright side: Many of the proposed case mix changes won’t make a difference "because we were only using them as the reason for aftercare," Adams says. Effective this year, CMS will no longer award case mix points for resolved diagnoses so these diagnoses aren’t being reported as frequently.