Home Health ICD-9/ICD-10 Alert

Here's how to demonstrate medical necessity and come out on top under medical review.

Accurately coding resumption of care (ROC) assessments paints a more specific picture of the care you provide and can make the difference between a denial and a paid claim. Follow our expert tips to make sure you're accurately reporting ROC diagnoses.

The accuracy of the ROC is still essential to your agency's success -- don't let it slip just because payment is no longer derived from it (except in one instance), says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR ��" Coding Done Right in Denton, Texas.

Understand How ROC Coding Impacts Your Agency

When you fully code the ROCs you submit, you provide the most up-to-date information on the patient's condition to describe the current status, says Judy Adams, RN, BSN, HCS-D, COS-C, president and CEO of Adams Home Care Consulting in Chapel Hill, N.C. This can have an impact on outcomes -- and in the future outcomes may be the most important determinant to payment for home health, she says.

"The official coding guidelines require that whenever we are describing a patient's health status that we should be including codes at the highest degree of accuracy and include everything necessary to fully describe the patient's condition at that point in time," Adams says.The number and types of diagnoses add to the true reflection of the patient's condition.

There are two different beginning time points for an outcome episode -- start of care (SOC) and ROC, says Selman-Holman cautions. Answering the ROC correctly will influence the risk adjustment and the beginning points of your outcome episodes.

Diagnosis selection, sequencing and code assignment at ROC is critical, says Trish Tulloch,RN, BSN, MSN, HCS-D, senior consultant with RBC Limited in Staatsburg, N.Y. The diagnoses reported at ROC reflect patient clinical complexity and changes in the plan of care. These ROC diagnoses will reflect patient changes that may also require a change in care and services.

Key: Accurate ROC coding is essential to demonstrate medical necessity and withstanding the scrutiny of medical review, Tulloch says. The appropriate and often revised diagnoses reflect plan of care changes and support medical necessity for changes in the plan of care.

At ROC, you have a new opportunity to take stock of your patient's health. "Selection and sequencing of the ROC diagnoses is directly related to assessing a patient's changes, and the changes needed in the ROC plan of care," says Tulloch.

• When completing the ROC, the clinician should ask:
• How has this patient changed post ROC?
• Do the current diagnoses (from the start of care or SOC) reflect this patient's changed clinical complexity?
• Do the current diagnoses reflect the changes that need to occur in the ROC plan of care?

With these questions answered, the clinician will select and sequence the diagnoses present when the patient was discharged from the facility, Tulloch says. Then the coder can assign the correct ICD-9 codes.

Lend a hand: Busy clinicians may not feel they have the time to scrutinize diagnoses during the ROC visit. So assistance and support from their supervisors and other agency support staff is helpful, Tulloch says.

In addition, updated information on the ROC may also impact how you answer a number of the OASIS C questions, Adams points out. Pay special attention to OASIS items completed only at transfer and discharge

For example: M1500 (Symptoms in heart failure patients) and M2400 (Intervention synopsis) are OASIS C items that are only answered at transfer and discharge, Adams says. Item M1500 only applies if the patient had a diagnosis of heart failure at the last OASIS assessment. Heart failure is a common reason for hospitalizations and the ROC could be the first time this diagnosis is added to the plan of care. Item M2400 is also completed at transfer and discharge only so updating the plan of care and diagnoses at ROC could make a significant difference in the response to this item.

Coding Scenario: Your patient was admitted to home health with congestive heart failure (CHF),coronary artery disease (CAD), hypertension (HTN) and emphysema. She is using oxygen intermittently.

On admission, you would report the following diagnoses for this patient, Tulloch says:

M1020a: 428.0 (Congestive heart failure, unspecified)

M1020b: 492.8 (Other emphysema)

M1020c: 401.9 (Essential hypertension, unspecified)

M1020d: 414.00 (Coronary atherosclerosis; of unspecified type of vessel, native or graft)

M1020e: V46.2 (Supplemental oxygen)

However, early in the home health episode, the patient has a mild stroke causing generalized muscle weakness and is admitted as an inpatient. An MRI confirms the mild stroke. The patient refuses transfer to a rehab facility and returns home. She requires physical therapy and occupational therapy as well as nursing services, as a result of the stroke. You will also be monitoring the patient's anticoagulant use.

When your agency performs the ROC assessment, the diagnoses selection and sequencing reflects a change in the plan of care for both therapy services and aide services, Tulloch says. You would list the following diagnoses at ROC, Tulloch says:

M1020a: 438.89 (Other late effects of cerebrovascular disease)

M1020b: 728.87 (Muscle weakness [generalized])

M1020c: 401.9

M1020d: 428.0

M1020e: 492.8

M1020f: V58.83 (Encounter for therapeutic drug monitoring)

Other pertinent diagnoses: V58.61 (Long-term [current] use of anticoagulants).

The ROC plan of care and OASIS reflect the changes in the patient's clinical complexity, and revised therapy services, says Tulloch. The revised ROC diagnoses support medical necessity for additional therapy services. The final episode claim will be based on the actual therapy threshold achieved during this episode, and may positively impact agency reimbursement as well.

If this record is selected for integrity or MAC audits, the ROC would accurately reflect the vital patient changes that drive plan of care changes, Tulloch says.