Home Health ICD-9/ICD-10 Alert

Secondary doesn't mean second in diagnosis coding.

The Centers for Medicare & Medicaid Services (CMS) says only the assessing clinician can determine the primary and secondary diagnoses and assign the severity. As a coder, you can't assign the codes or change the sequencing without clinician agreement.

But you can confer with the clinician if you think other sequencing is more accurate -- which may just result in improving your agency's bottom line.

Ensure your diagnosis codes are sequenced correctly with the following guidelines from Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principle of Selman-Holman & Associates in Denton Texas.

1. Choose the right principle diagnosis. This should be the chief reason for home care -- the diagnosis most related to the current plan of treatment. It may be related to the patient's most recent hospital stay, but that's not always the case. It must always be related to the services your agency provides.

Make a choice: If two or more diagnoses meet this definition of the principle diagnosis, just choose one. But the principle diagnosis should be the one that represents the most acute condition and requires the most intensive services.

Mistake: Don't choose the principle diagnosis based solely on which skilled discipline has the most visits. This is rarely the determining factor, Selman-Holman says.

Secondary doesn't mean second in home health diagnosis code sequencing. To help reduce confusion over this, CMS has renamed these co-morbidity diagnoses "other."

Secondary diagnoses include all conditions that coexisted at the time the plan of care was established, those which developed subsequently, or those that affect the treatment or care. Secondary diagnoses include those actively addressed in the plan of care as well as any co-morbidity affecting the patient's responsiveness to treatment and rehabilitative prognosis, even if the condition is not the focus of any home health treatment itself, according to chapter 8 of the OASIS instructions.

Recent direction from CMS states that if the diagnosis impacts the patient's responsiveness to treatment, then the diagnosis should at least be mentioned in the Plan of Care.

Mistake: Don't include codes for conditions that have only a historical significance and won't impact patient progress or outcome.

Exception: List history V codes when the historical condition has an impact on the current care or influences treatment such as when your patient has a history of cancer.

The AHA's Coding Clinic advises that certain comorbidities should always be coded if the patient has them because they impact care even in the absence of documented active intervention. These diagnoses

include:

• Diabetes

• Hypertension

• Chronic diseases such as Parkinson's

• Chronic obstructive pulmonary disease (COPD) and asthma

• Blindness

• Status amputation

• Peripheral vascular disease (PVD)

• Coronary artery disease (CAD), chronic heart failure (CHF)

• History of malignant neoplasm when care is directed at a current neoplasm or is otherwise impacted.

4. Ask the right questions. After listing the chief reason for home care as the principle diagnosis, Selman-Holman suggests asking the following questions to help make sequencing decisions:

• Which of the other diagnoses need active intervention?

• Which of the other diagnoses will impact the healing or recovery of the primary diagnosis the most?

• What other diagnoses will impact the care even if interventions aren't needed?

• Remember that V codes are not diagnoses in the true sense of the word; they represent reasons for encounter. CMS states in Attachment D that numeric codes reflect the seriousness of the patient's condition better than V codes. Use V codes sparingly and only as necessary, i.e., according to official coding guidelines.

Although CMS indicates that there is no requirement to sequence in order of the plan of care, it just makes sense that your clinical documentation will support the diagnoses selected if the clinician/coder considers the plan of care when sequencing diagnosis codes, Selman-Holman says.

Note: You won't have to code in order of severity. CMS differentiates between severity index and seriousness of the patient's condition.