Home Health ICD-9/ICD-10 Alert

Answer three questions before listing 401.9 as primary.

If you've been listing hypertension (HTN) as a primary diagnosis for your patients, you may be putting yourself at risk of Additional Development Requests (ADR). And if you don't have the documentation to back up your diagnosis choice, you could be looking at focus reviews and denials.

The problem: Some coders make the mistake of seeing a hypertension diagnosis in the medical record and automatically listing 401.9 (Essential hypertension; unspecified) as primary, says  Arlene Maxim, RN, founder of A.D. Maxim & Associates, A.D. Maxim Seminars, and The National Coding Center in Troy, Mich. Clinicians should base their choice of primary diagnosis on which condition will receive the most intensive services, says Cherlynn Taylor, senior coding coordinator with The National Coding Center.

Before listing hypertension as the focus of care, Maxim says coders should ask some questions:

• Have there been changes in the patient's hypertension?

• Have there been changes in the patient's HTN medication?

• Is your agency doing something to help this patient with his HTN?

If your documentation indicates a yes answer to these questions, you may be able to report HTN as primary. But some coders aren't thoroughly reading the discharge paperwork and determining which code is most appropriate to list as primary, Maxim says. HTN gives case mix points, so it's bound to draw scrutiny from the home health intermediaries.

Caution: A visit frequency of once a week for nine weeks doesn't indicate a significant problem with this HTN, Maxim points out. If you're going to list HTN as primary, your staff should need to visit the patient more regularly.

Agencies are being hit with ADRs related to coding hypertension as primary, Maxim warns. This can lead to focus reviews and denials.

To help keep your claims safe, make sure the documentation supports the diagnoses you submit, says Taylor.

Sparse and incorrect documentation can lead to headaches in the end. To improve your coding accuracy, Taylor recommends ditching coding cheat sheets and double-checking the diagnosis codes your software "spits out."

Good practice: Don't rely on check boxes. Detailed, supportive documentation is the key to safeguarding your claims.

There is absolutely nothing wrong with coding hypertension as primary, adds Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDRCoding Done Right in Denton, Texas. The real issue with hypertension is not the coding itself. The problem arises when hypertension appears as primary for episode after episode, putting the need for skilled care in doubt. When you code a condition, such as hypertension, as primary for a long period of time (more often than two to three episodes), then the medical reviewers start doubting that the patient truly has a potentially fluctuating condition -- the requirement for skilled observation and assessment.

Bad habit: Sometimes when recertifying a patient, the clinician simply checks off "no changes since previous assessment," Taylor says. But what was the previous assessment? Some things may have been resolved or gotten better since the last assessment.

Clinicians should summarize the care the agency has provided previously on the recertification paperwork. Otherwise they open up the potential for accusations of upcoding.

When an agency stands accused of upcoding, the real problem may be under-documenting, Maxim says. Staff should receive OASIS documentation retraining to aid in correct OASIS answer choices as well as how to provide supportive documentation to Medicare, Taylor says.

Coding example: Your new patient is recovering from gall bladder surgery. While she was in the hospital, her hypertension exacerbated and she contracted an upper respiratory infection causing her chronic bronchitis to exacerbate. You are providing aftercare following surgery, but the focus of care is the exacerbated hypertension. Documentation that supports your choice includes the blood pressure readings, specific parameters set for the patient for notifying the physician, contacting the physician when the blood pressure is out of those parameters, teaching on medications, diet and disease process, and adjustments of medications. To code for this patient, Selman-Holman says to list the following codes:

• M0230/M1020a: 401.9 -- Essential hypertension, unspecified

• M0240M1022b: 491.22 -- Obstructive chronic bronchitis; with acute bronchitis

• M0240/M1022c: V58.75 -- Aftercare following surgery of the teeth, oral cavity, and digestive system, NEC

• M0246/M1024a(3): 575.10 -- Cholecystitis, NOS.

You can earn case mix points for hypertension, chronic bronchitis, and cholecystitis in this scenario, says Selman-Holman.