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Home Health ICD-9/ICD-10 Alert

Coding How-To:

Connect the Dots to Keep Your Therapy Reimbursement Flowing

Published on Sun Jan 16, 2011

Make certain therapy-related diagnosis codes are supported by OASIS functional items.

The Centers for Medicare & Medicaid Services has therapy in the cross hairs. Make sure you're doing your part to prevent audit trouble.

Keep an Eye on Documentation

When it comes to keeping your therapy claims audit-proof, it's not the diagnosis codes you list that make the difference -- it's the therapist's documentation. And it's "your responsibility as a coder to be an advocate with the therapist to connect the dots between the documentation and the diagnosis codes," says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, HCS-O director of coding with Foundation Management Services in Denton, Texas.

The therapist's documentation should describe the impairments or symptoms that are the consequence of the patient's disease, disorder, or condition, Twombly says. The therapist should also document the patient's functional limitation -- the inability to perform a task or action because of the impairment that the patient's disease, disorder, or condition has caused, she says.

As a coder, you must report the pathology -- the disease, disorder, or condition that has caused the patient's need for home health therapy, Twombly says. And all diseases and conditions must be diagnosed by the physician before you can code for them. But you should also be checking the therapist's documentation to make certain it supports the diagnosis you report.

Look at the assessment, therapy evaluation, and visit notes to make certain that the documentation supports the diagnosis codes listed, Twombly says.

Check OASIS Functional Items

The answers to the OASIS functional items should also support the pathology you report, Twombly says. These include:

  • M1810 -- Dressing upper body;
  • M1820 -- Dressing lower body;
  • M1830 -- Bathing;
  • M1840 -- Toileting;
  • M1850 -- Transferring; and
  • M1860 -- Ambulation.

Tip: The OASIS C data items you should review depend upon the type of therapy your agency will provide, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. For example, the responses to OASIS items dealing with verbal communication, understanding, and hearing should support speech therapy. And in addition to the functional items listed above, occupational therapy can also be related to the M1200 vision item, she says.

For example: Your new patient was admitted for coronary artery bypass graft aftercare. Nursing will provide observation and assessment. Physical therapy and occupational therapy will address her weakness, difficulty with transfers, and dressing ability. Therapy is the primary discipline.

For this patient, you would list the following codes, Twombly says:

  • M1020a: V58.73 (Aftercare following surgery of the circulatory system, NEC);
  • M1022b: 414.00 (Coronary atherosclerosis of unspecified type of vessel, native or graft); and
  • M1022c: V45.81 (Postsurgical aortocoronary bypass status).

There's no need to list anything in M1024 for payment because all of this patient's diagnoses are current, Twombly says.

As a coder, you have the responsibility to make certain that the therapy-related diagnosis codes you list are supported by the answers in the functional portion of the OASIS assessment. In this scenario, you should check that the answers to M1810, M1820, and M1850 correlate with the diagnoses you have listed and demonstrate the patient's functional limitations.

Talk to the Therapist

If the answers to the OASIS functional items don't support the pathology you have coded, you should contact the therapist, Twombly says. Ask whether there is another pathology you should be coding. Or perhaps there is something the therapist needs to elaborate on or amend to the documentation. Discuss your concerns, she says.

The therapist's documentation should also:

Highlight the patient's progress toward measurable goals.

Document measurable improvement in functional ability. If the patient isn't able to show improvement, the functional limitation may have progressed into a disability for which home health therapy is no longer appropriate, Twombly says.

Document any complicating co-morbidities.

For example: Your patient has been on service for two certification periods with a diagnosis of congestive heart failure. Nursing was discontinued after 60 days. Therapy remained to work on the patient's shortness of breath, difficulty dressing, and ability to climb stairs.

The second certification period is ending and currently the patient's shortness of breath has improved and she is able to dress herself, but she remains unable to climb the three steps to her bedroom. The therapist documents that there is no expectation of continued improvement.

In this case, the patient should be discharged, Twombly says. The therapy documentation shows that she has made progress toward measurable goals with her improvements in shortness of breath and dressing ability. But her inability to climb stairs has gone from a functional limitation to a disability.

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