Home Health ICD-9/ICD-10 Alert

Hypertension doesn’t add resource requirements, CMS says.

Say goodbye to case mix points for hypertension diagnoses if recently proposed cuts to the Medicare payment rates become final. In its proposed prospective payment system rule for home health agencies published in the July 23 Federal Register, the Centers for Medicare & Medicaid Services sets out a 4.75 percent cut to Medicare payment rates for 2011. That would bring the current base rate of $2,312.94 down to $2,198.58, and will cut about $900 million from Medicare HHA payments next year.

In its case mix examination, CMS also found that agencies were using hypertension diagnosis codes more often once it became a case mix code in 2008.“

Our analysis of 8 years of claims shows that reporting of this diagnosis grew exceedingly quickly in 2008,” CMS says in the rule. “The data indicate a sudden jump of approximately 12 percentage points in reporting of unspecified hypertension when the refined HH PPS added hypertension as a case mix code in 2008. Annual changes in use of this code were small up until 2005 (in the range of 0.1 to 2.4 percentage points), after which there were two years of 6-percentage point increases, followed by the 12-percentage point increase coincident with the 2008 refinements.”

Accordingly, CMS proposes dropping two hypertension codes -- 401.9 (Unspecified essential hypertension) and 401.1 (Benign essential hypertension) -- from the case mix list. “The services utilization associated with the most commonly reported hypertension diagnosis code, hypertension, unspecified, no longer is responsible for added resource requirements in home care,” CMS maintains.

“Hypertension is an accepted co-morbidity that is always coded because it can influence a patient’s health and resource usage. This is supported by the AHA Coding Clinic for ICD-9-CM, considered official guidance,” says Lisa Selman-Holman, JD, BSN, RN, HCSD, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

“We had been teaching agencies for several years the importance of adding the co-morbidities according to OASIS as well as the Conditions of Participation. When PPS 2008 commenced, providers realized the importance of those co-morbidities and perhaps increased coding of the other conditions that can impact the plan of care or rehab prognosis, Selman-Holman says.

“CMS is concerned about the increase in the coding of unspecified hypertension and decrease in malignant hypertension, but fails to recognize that the official coding guidelines require us to code unspecified hypertension when the physician has not specified malignant or benign hypertension,” Selman-Holman says.

Implementing a case mix cut and cutting these two codes is a “double hit,” NAHC protests. “If the hypertension scoring element is removed, CMS should not impose a permanent rate reduction through the coding creep adjustment,” the trade group says. “It is one or the other that is the appropriate approach, not both.”

Timeline: Comments on the proposed rule are due Sept. 14. Final payment changes will take effect Jan. 1.

Note: The proposed rule is at http://edocket.access.gpo.gov/2010/pdf/2010-17753.pdf or e-mail Jan Mater-Cavagnaro with “2011 PPS Proposed Rule” in the subject line for a free PDF copy.

Sign up for an Eli-sponsored audioconference on the PPS proposed rule provisions with speaker Mark Sharp of BKD in Springfield, Mo. Information is at www.audioeducator.com.