Home Health ICD-9/ICD-10 Alert

It's up to you to 'connect the dots' between documentation and coding.

Your therapy claims are under fire. As of April 1, the Centers for Medicare & Medicaid Services requires therapists to make functional reassessment visits on the 13th and 19th visits and every 30 days. Plus, high therapy utilization is garnering the interest of medical reviewers. As a coder, your expertise can help prevent delayed and denied payments.

Problem: Claims targeted for high therapy often have problems such as failing to show a prior level of function, missing or insufficient documentation, and errors in orders, said Latesha Walker with the Centers for Medicare & Medicaid Services, at the National Association for Home Care & Hospice's annual March on Washington conference.

Understanding the Disablement Therapy Model can help you to narrow in on OASIS and documentation issues that can trip up your claims, says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, director of coding with Foundation Management Services in Denton, Texas.

Coders can use the four levels of the Disablement Therapy Model, the popular reahbilitation tool shown below, to help make sure the diagnosis codes they list are supported in the therapist's documentation

Coding example: Your patient was admitted to home health with a new diagnosis of congestive heart failure (CHF). She has shortness of breath, weakness, and edema related to the heart failure. She is unable to climb the three steps to her bedroom and is unable to dress herself. Nursing, physical therapy, and occupational therapy will all see the patient, but therapy will be the primary discipline in the home.

In this example, the CHF is the pathology, Twombly says. The patient's shortness of breath, weakness, and edema are impairments, or symptoms of the pathology. And the patient's inability to climb steps and dress herself are functional limitations.

As the coder, you need only list one diagnosis code for this patient: 428.0 (Congestive heart failure, unspecified), Twombly says. The symptoms listed are all integral to this condition, so you don't need to list them, but you should also check to make certain that the documentation supports the diagnosis.

How? Look to the OASIS functional questions to make certain the responses support the diagnosis code(s) you have listed. These include:

If the responses to these items don't match the therapist's notes or support the pathology you are coding, confer with the nurse and therapist, Twombly says. This can be especially important when your agency has a nurse complete the OASIS assessment for all patients. Ask whether there is another pathology that is more appropriate to code.

Verifying that the OASIS assessment documentation supports the diagnosis codes you list for your therapy patients will help keep your claims secure. "It's the coder's job to connect the dots," Twombly says.

Another example: Your patient was admitted for aftercare related to his total hip replacement due to degenerative joint disease (DJD) of the hip. Nursing is going out for observation and assessment. Physical therapy will provide joint rehab including gait abnormality. Occupational therapy will address the patient's difficulty in dressing of the lower body, bathing, and transfers. Therapy is the primary discipline in the home.

In this example, the patient's DJD and hip joint replacement are both pathologies, Twombly says. His abnormal gait is the impairment. And the difficulty dressing the lower body, bathing problems, and transferring issues are all functional limitations caused by the impairment.

To code for this patient, Twombly suggests listing the following codes:

As a coder, you won't list diagnosis codes for the impairments or functional limitations, but you should check to make certain that the therapist's documentation and the OASIS assessment both describe the functional limitations accurately, Twombly says. For this patient, that means checking the answers to M1820, M1830, and M1850 to make certain they match the therapy documentation and accurately support the patient's pathologies.