Home Health ICD-9/ICD-10 Alert

Repeat episodes attract intermediary edits.

Coding accuracy can keep your agency from wasting time and money providing the intermediary with medical records -- and speed reimbursement.

Regional home health intermediary Cahaba GBA promises to continue edits for non-start of care claims with a primary diagnosis of diabetes and a secondary diagnosis of congestive heart failure.

Protect yourself: With the 2008 PPS refinements beginning Jan. 1, repeat episodes will draw more intermediary attention, says coding consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates. Because later epi-sodes generate more revenue, reviewers will scrutinize length of stay more carefully than they have in the past, she says.

What to expect: Edit 5THBK will select claims that meet these parameters from across the provider community, Cahaba says. The intermediary will then review the claims for billing and coding errors as well as for local coverage determinations and compliance with Centers for Medicare & Medicaid Services' guidelines.

Protect yourself from edits: Cahaba reports three main reasons for denials resulting from this edit: inadequate documentation to support skilled nursing visits, failure to respond to requests for medical records and inappropriate use of the diabetes primary diagnosis.

Diabetes is one of the most commonly upcoded diagnoses in home health care, Selman-Holman tells Eli. Coders often sequence diabetes as primary with the rationale, "But the patient probably wouldn't have this problem if they didn't have diabetes." This kind of reasoning is not valid and should not be used for choosing the primary diagnosis.

Example of upcoding #1: The patient has a pressure ulcer and its treatment is the primary focus of care, but diabetes is wrongly sequenced first. The rationale was that the diabetes causes poor circulation, thus the pressure ulcer was the result of the diabetes and the diabetes should be sequenced as primary.

Example of upcoding #2: Home care saw the patient for diabetic osteomyelitis and diabetes was correctly sequenced first. When the patient was recertified, the patient refused continued treatment of the osteomyelitis and care was directed at the patient's hypertension. Very few interventions were performed for diabetes. But using the reasoning that the diabetic osteomyelitis was still the worst problem the patient had, it was incorrectly coded as primary.

Don't forget: Diagnosis and documentation are co-dependent. The clinical documentation must support the primary diagnosis choice. (See Eli's Home Health ICD-9 Coding Alert, Vol. 2, No. 10, p. 74 for more about correct diabetes coding).

Note: For additional information on the edit, go to page 19 at http://www.cahabagba.com/part_a/education_and_outreach/newsletter/200710_rhhi.pdf.