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Home Health ICD-9/ICD-10 Alert

CODING COACH:

Bid Farewell To Costly Primary Diagnosis Coding Errors

Published on Sun Mar 27, 2005

Hint: M0230 really comes after M0825

Four years into the prospective payment system, agencies are still choosing the wrong primary diagnosis - and it's costing them a bundle.

When regional home health intermediary Palmetto GBA analyzed the reasons for claims downcodes, the biggest reason by far was errors in the primary diagnosis. Here's what you need to know to choose correctly every time.

The primary diagnosis placed in M0230 of the OASIS assessment must be the diagnosis most closely related to the home health plan of care, focusing on skilled services, the Centers for Medicare & Medicaid Services instructs in attachment D to Chapter 8 of the OASIS User's Manual.

Caution: Don't just use the diagnosis for a recent hospital admission or the most recent medical problem, even though this diagnosis may be on the intake form.

Experts offer these tips for deciding which diagnosis is primary:
 

  • First complete the OASIS assessment, recommends Grand Rapids, MI-based consultant Arlene Maxim with Healthcare Management Consultants. This gives you much of the information you need to determine which diagnosis is primary.
     
  • Look at the problems you found during the assessment and decide how you will address them, says consultant Pat Sevast with American Express Tax and Business Services in Timonium, MD. Each problem is likely to be linked directly to a diagnosis and you can list them in order of priority, she adds.
     
  • Consider the whole picture. Ask what drives the plan of care, suggests coding consultant Prinny Rose Abraham with Minneapolis-based HIQM.
     
  • Check acuity levels. When a patient has multiple medical problems and is being treated by multiple disciplines, your primary diagnosis usually reflects "the highest level of acuity" as listed from 0 to 4 in M0230 and M0240, Sevast explains.
     
  • Think about visit frequency. See which diagnosis is receiving the most attention in the home health treatment plan. But don't let the visit count be the only factor you consider, experts warn. 
     
  • Ask if the record supports the diagnosis you've chosen, Sevast adds.

    Accuracy Guards Against Fraud Charges

    Warning: Upcoding remains a major government focus. Warnings from the HHS Office of Inspector General point out that one vulnerability of PPS is the opportunity for agencies to upcode the diagnosis to increase clinical severity points -resulting in overpayments.

    Because the ICD-9 codes used to answer OASIS questions M0230, M0240 and M0245 affect the case-mix weight and are part of the calculation for the home health episode payment rate, the feds are scrutinizing them, Sevast cautions. This means codes have to be both valid - having the right number of digits - and accurate in reflecting the patient's condition, she adds.

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