Home Health ICD-9/ICD-10 Alert

Do you know which diagnoses you should code every time?

It might seem obvious, but even before you start selecting diagnosis codes you need to know which diagnoses to code -- this trips coders up more than you might think. Make sure you have a clear understanding of what makes a primary diagnosis versus a secondary diagnosis and which diagnoses you should always report to paint the most accurate picture of your patients.

The primary diagnosis is the focus of the care you're providing. Keep in mind that this may be different from the referral diagnosis, said Pamela Teenier, assistant vice president for Medicare with Gentiva Health Services, while speaking at the 2008 National Association for Home Care & Hospice annual meeting. Teenier offered the following guidelines for making the right choice:

• The primary diagnosis should be the diagnosis most related to the current plan of treatment.

• The primary diagnosis may or may not be related to a recent hospital stay.

• The primary diagnosis must relate to skilled services your agency is providing.

• If you're treating multiple diagnoses concurrently, the primary diagnosis should represent the most acute condition and the most intensive services.

• To determine the primary diagnosis, ask yourself "Why is home health seeing the patient?"

Secondary diagnoses are other conditions that coexisted with the primary diagnosis when the plan of care was established, Teenier reminded attendees. Some coders confuse secondary as meaning that the diagnosis must be listed in the second slot (M0240b), but this is incorrect. Secondary diagnoses mean those pertinent diagnoses that do not qualify as the primary diagnosis, so they should be listed in one of the M0240 slots or as another diagnosis on the plan of care.

Helpful: Medicare has renamed these diagnoses "other diagnoses."

Secondary diagnoses include co-morbidities that affect the patient's response to treatment or rehab prognosis, Teenier said. Do not list a diagnosis as secondary if it has been included in the record only for history.

Teenier suggests asking the following questions to make sure you report all pertinent secondary diagnoses:

• Is there more than one problem targeted for intervention?

• Are there any co-morbidities that may impact the outcome?

• What medications is the patient taking?

• What services are needed to achieve goals and outcomes?

• If more than one discipline is involved, which will have the greatest intensity?

Finding all of your patient's diagnoses can be like a scavenger hunt, but one way to make sure you don't miss anything is to do some "chart diving," Teenier said. Digging deeper into the charts will help you to paint the most detailed picture of your patients' diagnoses.

When listing diagnosis codes, make sure to examine the following resources to help provide the most accurate picture of your patients and the care they require, Teenier suggested:

• Referral documents;

• Discharge documents;

• Medication list: Looking at the medication list may reveal additional diagnoses;

• Patient and family report: This may lead to discovering hidden diagnoses such as a history of breast cancer;

• Physician notes; and

• Previous admissions.

Report These Diagnoses Every Time

Certain co-morbidities will impact your patient's plan of care no matter what, and these diagnoses should always be included in your secondary list even if no active intervention is required. Among the conditions you should always identify are:

• Congestive heart failure (CHF) -- report with a code from the 428 (Heart failure) category;

• Coronary artery disease (CAD) -- report with a code from the 414.0 (Coronary atherosclerosis) subcategory;

• Peripheral vascular disease (PVD) -- report with 443.9 (Peripheral vascular disease, unspecified) unless specified as vascular or arterial or diabetic;• Chronic obstructive pulmonary disease (COPD) -- report with a code from the 490-496 (Chronic obstructive pulmonary disease and allied conditions) series;

• Diabetes -- report with a code from the 250 (Diabetes mellitus) or 249 (Secondary diabetes mellitus) categories;

• Blindness -- report with a code from the 369 (Blindness and low vision) category;

• Hypertension -- report with a code from the 401-405 (Hypertensive disease) series;

• Amputation status -- report with a code from the V49. 6 (Upper limb amputation status) or V49.7 (Lower limb amputation status) subcategories. Note: Do not report the amputation status code if your patient has a complication of the amputation;

• Chronic diseases such as Parkinson's disease (332.0) or multiple sclerosis (340); and

• History of malignant neoplasm when care is directed at a current neoplasm or is otherwise impacted -- report with a code from the V10 (Personal history of malignant neoplasm) category.