Home Health ICD-9/ICD-10 Alert

A simple sequencing secret could earn you an extra $139.84 in NRS payment.

With the 2008 PPS revisions, reimbursement for non-routine supplies (NRS) changed from a flat rate per episode to using OASIS to determine the amount of NRS payment. With this change, it's even more important to make certain you're coding correctly for patients whose conditions trigger NRS points.

There are twelve diagnosis categories that earn non-routine supply points, said Judy Adams, RN, BSN, HCS-D, with LarsonAllen in Charlotte, NC during a recent Eli-sponsored audioconference. These diagnosis categories include the following:

Accurate ICD-9 coding is vital for correct reimbursement, Adams says. For example, when you're coding for diabetic ulcers, you'll only receive NRS points for those reported as follows, Adams says:

• 250.8x (Diabetes with other specified manifestations);

• 707.1x (Ulcer of lower limb except decubitus).

Sequencing alert: You must list diabetes as a primary diagnosis in order to gain the 20 NRS points.

If you're coding for a diabetic ulcer and list 250.6x (Diabetes with neurological manifestations) or 250.7x (Diabetes with peripheral circulatory disorders), you won't gain the 20 diabetic ulcer NRS points, Adams says.

Good news: You will gain NRS points for non-pressure or non-stasis ulcers when you report 707.1x for neuropathic or atrial ulcers. So while you can't gain the 20 diabetes points, you can secure 13 points for the ulcer, whether the ulcer is listed as a primary or other diagnosis.

Coding example: Your patient has diabetic peripheral neuropathy, hypertension, and a diabetic ulcer on the plantar surface of the right foot. He was referred to your agency for nursing and physical therapy. The ulcer is the focus of the care. List the following codes:

• 250.80 (Diabetes with other specified manifestations; type II or unspecified type, not stated as uncontrolled);

• 707.14 (Ulcer of heel and midfoot);

• 401.9 (Essential hypertension, unspecified);

• 250.60 (Diabetes with neurological manifestations; type II or unspecified type, not stated as uncontrolled); and

• 357.2 (Polyneuropathy in diabetes).

In this case, the ulcer is the primary diagnosis, although it is listed second due to mandatory multiple coding rules for manifestations. This sequencing would earn you 20 points or $139.84 in NRS payment, Adams says.

If the ulcer diagnosis were listed as an "other" diagnosis, you wouldn't earn points for the diabetic ulcer category, but you would earn the 13 points or NRS reimbursement of $51.00 for the non-pressure and non-stasis ulcers category, Adams says.

One key to securing NRS reimbursement is to dig through all of the documentation before coding, Adams says. You may be missing out on something if you code based only on the referral information.

Coding example: A patient was referred to your agency for aftercare following incision and drainage (I&D) of an abscess of the abdominal wall. The patient is receiving oral antibiotics. To code for this patient, you would list the following in M0230:

• 682.2 (Other cellulitis and abscess; trunk).

Note: This patient is still on antibiotics so it is inappropriate to code a V code.

OASIS M0420 would indicate daily pain for this patient, and the combination of diagnoses and OASIS answers would bring your agency $51.00 for NRS reimbursement and would classify the patient as C2.

However, suppose you have the same patient, but you read further into the documentation to examine the operative report. There you learn that the patient had necrotic tissue and imbedded mesh removed. You also find that the antibiotics are being used to treat a residual infection of the joint prosthesis. With this additional information, you could code as follows:

M0230

996.69 (Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft)

682.2

OASIS 420 would still be answered with "daily pain" for this patient. You won't gain any NRS points for the infection diagnosis in M0230, but you can answer '3' to M0488, which indicates that the patient has a non-healing surgical wound.

Coding for the patient this way brings in $139.84 in NRS reimbursement and classifies the patient as a C3.