Home Health ICD-9/ICD-10 Alert

Published on Sun Nov 20, 2011 PDF

Good coding practices know no payer bounds.

Have you ever been told that because Medicaid reimbursement isn't based on coding, it's not necessary to spend time following ICD-9 coding guidelines and determining sequencing for Medicaid these patients? This belief is not only wrong, it could prove costly. Read on for expert advice on how to respond when confronted with doubts about the relevance of ICD-9 coding accuracy.

Limiting coding accuracy based on payer source ultimately leads to reductions in home health payment because all payment systems look at the type of coding that has been done historically, says Judy Adams, RN, BSN, HCS-D, COS-C with Adams Home Care Consulting in Chapel Hill, N.C.

Coding rules are not designed to change by payer; they are established to describe the patient's current health status no matter who pays the bill, Adams says.

"Anyone in any practice setting, regardless of the payer, must follow the official coding guidelines," points out Sparkle Sparks, MPT, HCS-D, COS-C, with Redmond, WA-based OASIS Answers.

Proof: The Centers for Medicare & Medicaid Services (CMS) state that the codes you list in M1010, M1016, M1020, M1022, and M1024 "must comply with the "Critera for OASIS Diagnosis Reporting'" detailed in Appendix D. And Appendix D, section D1 states "HHA clinician/coders are expected to comply with ICD-9-CM coding guidelines when assigning primary and secondary diagnoses to the OASIS items M1020 and M1022. Refer to the ICD-9-CM Official Guidelines for Coding & Reporting." You send the OASIS to both Medicare and Medicaid, so following these guidelines is required for either payer, Adams says.

OASIS-C guidance requires that all Medicare, including HMOs, and all Medicaid, including HMOs, (excluding pediatrics) patient information from the OASIS be transmitted for data purposes. "That coding plays a role in the risk adjustment for your outcomes, so ignoring the accuracy of coding on those patients can lead to dire circumstances," 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.

Furthermore, Appendix D, section B -- OASIS Integrity advises you to "Avoid the practice of allowing the case mix status of a diagnosis to influence the diagnosis selection process. HHAs are expected to prevent 'Coding for Payment' from occurring." By that same logic, it would be wrong to deliberately not follow coding guidelines when payment isn't tied to the diagnoses you select.

Many of us remember when home health was not allowed to use V codes on the OASIS, Sparks says. However all that changed when the HIPAA Administrative Simplification Rule of Oct. 16, 2003 went into effect. This rule mandated that all entities covered under the Health Insurance Portability and Accountability Act (HIPAA) use the ICD-9-CM code set and its Official ICD-9-CM Guidelines for Coding and Reporting for reporting diagnoses and inpatient procedures.

Because all practice settings and all payers that transmit electronic medical information must adhere to HIPAA, that means this applies to everyone, regardless, Sparks says

Bottom line: "Coding is meant to be blind, deaf, and dumb to reimbursement," Sparks says. Coding is meant instead to describe the patient's health condition and care needs.

The Official Coding Guidelines come from the cooperating parties -- 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 Coding Guidelines.

You'll find a copy of the cooperating parties' Official ICD-9-CM Guidelines for Coding and Reporting, in the front of your ICD-9 coding manual. It's updated every year, and you can see the most recent version here: www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf.