Home Health ICD-9/ICD-10 Alert

Are you sure you're up to date on the instructions for completing M1024?

As a home health coder, work often centers on asking questions and finding answers. But the hunt for definitive answers to some coding-related questions can be frustrating. Our experts help with some of your most pressing questions in part one of this article series on tricky diagnosis coding situations.

"I'm responsible to provide coding resources as well as OASIS information for our organization's agencies, but the more questions I get, the more frustrated and confusing the whole issue of coding is," says Jan McLain, RN, BS, LNC, COS-C, HCS-D, with Adventist Health System Home Care in Port Charlotte, Fla.

Question 1: "What sources of home health diagnosis coding information are authoritative -- the ones we must follow from a legal standpoint?" McLain asks the experts.

The official coding guidance comes from the cooperating parties, says Ida Blevins, RHIA, supervisor of reimbursement & information management with St. John's Hospital Home Health Services in Springfield, Ill. The cooperating parties are composed of the Centers for Medicare & Medicaid Services (CMS), the National Center for Health Statistics (NCHS), the American Hospital Association (AHA), and the American Health Information Management Association (AHIMA).

The rules for selecting primary and secondary ICD-9 diagnosis codes for home care must follow the Official Guidelines for Coding and Reporting, developed by the cooperating parties and found in the front of your ICD-9 coding manual. Other official publications include:

• Coding Clinic for ICD-9-CM, published by the AHA, and

• The OASIS User Manual, Appendix D, published by CMS.

"'Coding Clinic' is where you can send your coding questions to get official answers. This publication provides the official Q&A for ICD-9 diagnosis coding," says Sparkle Sparks, MPT, HCS-D, COSC, with Redmond, Wash.-based OASIS Answers.

Caution: Home care coders should take care to send only questions regarding coding guidelines and not about particular OASIS coding items such as M1024 to Coding Clinic, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR  Coding Done Right in Denton, Texas.

The folks at Coding Clinic do not concern themselves with OASIS issues, she adds.

Conquer the Case Mix Conundrum

When reporting a patient's diagnosis codes in OASIS, making certain your agency gets the case mix points and risk adjustment it deserves has long been a concern for coders. But recent changes to this section of the assessment document have lead to an increase in coder confusion.

Where once the decision as to whether you should list a diagnosis code in the "reimbursement slot" was relatively straightforward, newer guidelines have had coders referring to a cryptic list of times when it's appropriate -- or not -- to report a case mix diagnosis in M1024.

Question 2: So, is a case mix diagnosis a case mix diagnosis only if it meets the equation for case mix dollars? Or should any case mix diagnosis be entered in M1024 -- whether or not it meets all the criteria for the equations?

"By definition, a case mix diagnosis is always a case mix diagnosis," says Blevins. But as it stands now, although a case mix diagnosis may not impact reimbursement without the appropriate combination of elements, the diagnosis can still potentially impact your risk adjustment.

Old way: Prior to Jan. 1, 2010, official CMS guidance advised that if you listed a V code as a diagnosis in M0230 or the M0240s, you could report the numeric case mix code that underlies the V code in M0246, but only if the case met one of these conditions:

1) The V code in M0230 replaces a numeric case mix diagnosis, and the numeric case mix diagnosis falls in the diabetes, skin 1-traumatic wounds, burns, postoperative complications, or neuro 1-brain disorders and paralysis PPS diagnosis groups.

2) The underlying case mix diagnosis is resolved, so cannot be placed in M0240.

3) The case mix diagnosis is a fracture (traumatic or pathological) because coding guidelines restrict the fracture codes to settings providing active

treatment; therefore, fracture codes cannot appear in M0230 or M0240.

New way: CMS published a clarification related to M1024 in Appendix D of the OASIS User's Manual, effective Jan. 1, 2010, Blevins points out. The clarification states:

"If a V code assigned to M1020/M1022 replaces a case mix diagnosis code, HHAs no longer must always code a numeric diagnosis code in the optional case mix diagnosis M1024. ICD-9-CM coding guidelines state that certain rehabilitation and aftercare V codes need a secondary code in M1022 to describe a resolving condition or sequelae. If the diagnoses codes representing the underlying condition displaced by the V code are case mix codes, the HH PPS grouper will look to M1022 to award appropriate points."

Confusing: CMS still advises home care coders not to report resolved conditions in M1022 or acute fractures in M1020 and M1022, says Selman- Holman. CMS includes instructions for using M1024 in these situations and in the case when a V code replaces a case mix diagnosis that earns more points as a principal diagnosis than it would as an "other" diagnosis, she says.

Appendix D also states that the case mix diagnosis should be added to M1024 only if the Table 2a interaction criteria are met, notes McLain. The conditions listed above in condition number 1 for M1020 remain the same because some case mix diagnoses receive extra points when sequenced in M1020 or M1024 line a, she says.

Note: Watch for part 2 of this series in the February issue of Home Health ICD-9 Alert