Home Health & Hospice Week

Check your progress on codes that will RTP.

On Jan. 1, you need to hit the ground running when it comes to diagnosis coding under PDGM.

Home health agencies will have big cash flow problems if they continue to use diagnosis codes that are not valid in the Patient-Driven Groupings Model. While the Centers for Medicare & Medicaid Services has allowed a small group of dysphagia symptom codes to count in PDGM, most symptom codes — including some of the most popular ones HHAs use — will result in claims returns.

And HHAs will lose out on their rightful reimbursement if they use lower-paying primary codes when a higher-paying code is more accurate; or when they leave off a secondary code that could qualify the claim for a comorbidity adjustment.

Take these steps to make sure you don’t delay cash flow and throw away payments that should be yours:

1. Check your invalid code status. If you haven’t done so yet, you need to see how often you are using principal diagnosis codes that aren’t in PDGM’s case mix system, and thus will result in returned claims, urges coding expert Joan Usher with JLU Health Record Systems in Pembroke, Massachusetts.

Resource: For a free list of the top 75 invalid primary codes, based on 2017 data, email editor Rebecca Johnson at rebeccaj@eliresearch.com with “Top PDGM RTP Codes” in the subject line. “Look and see how often they show up,” Usher says of the top codes.

HHAs have been improving on their usage of codes that CMS deems as inappropriate, notes Chris Attaya with performance improvement software vendor Strategic Healthcare Programs in Santa Barbara, California. CMS formerly called invalid PDGM codes “Questionable Event” codes. The rate of “QE codes … was 8.4 percent as of June 2019, as compared to 11.7 percent in December 2018,” Attaya tells Eli.

Presumably, the rate will have decreased further since then.

2. Figure out what works instead. After scrubbing your claims of codes that will return claims under PDGM, you need to determine what codes to assign accurately instead. CMS is looking for more specificity and what is underlying any symptoms, Usher offers.

More work: That will often mean going back to the source — the referring physician, CMS instructs in the 2020 final rule.

Work on this now, rather than waiting until PDGM starts and your cash flow is at risk, Usher exhorts.

3. Educate physicians. The PDGM coding change is going to result in “a lot more back and forth with the physician office,” especially in the beginning, Usher cautions. Give them a heads up on what’s coming and let them know what type of information you’ll need in order for their patients to be able to qualify for home care services.

Watch out: Physicians and HHA staff alike will be frustrated that there isn’t a “one-to-one crosswalk” for those codes that aren’t valid under PDGM. For example, the popular M62.81 (Muscle weakness …) code could be substituted with at least 15 other codes, depending on what’s causing the condition, Usher observes.

Try this: In Massachusetts, HHAs and their representatives are proactively working with physician groups to convey the message that this change is coming, and why. “Educate them up front,” Usher recommends.

4. Educate your own intake staff. With PDGM’s 30-day billing periods and Request for Anticipated Payment payments reduced to 20 percent or cut altogether, time is of the essence in billing. That means agencies need to know patients’ correct diagnoses before it gets all the way to the diagnosis coding staff, Usher stresses.

Train your intake staff to ask pointed questions to solicit the accurate diagnosis coding information up front, so as not to waste valuable days. While intake staff don’t need to be responsible for assigning the principal diagnosis code, they should know enough about general coding terms to be able to ask “the right questions” of referral sources, Usher advises.

5. Look into HIE. As CMS alludes to in the final rule, HHAs may need to get their hands on actual documentation from referral sources to chase down the correct diagnosis code. A Health Information Exchange may allow you to do so much more quickly and expediently than traditional channels, even if you have to pay to join.

Definition: Electronic HIE “allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically — improving the speed, quality, safety and cost of patient care,” the feds note on HealthIT.gov.

If your state offers an HIE option for a relatively low fee, say $500, it would be worth it to be able to access hospital and other records efficiently and rapidly, Usher suggests.

6. Do not upcode. As with therapy utilization, LUPAs, and other PDGM fraud-and-abuse hot spots, CMS states its intention to monitor diagnosis coding changes for possible problems. “We do not support or condone coding solely for purposes of higher payment” i.e., upcoding, the agency says in the final rule.

On the other hand: CMS has set the behavioral adjustment cut because it believes HHAs “will improve their documentation and coding behaviors to more fully account for patient characteristics that impact resource use,” the rule notes. It will be key to be able to prove that any changes are accurate and compliant with documentation, experts note.