Home Health ICD-9/ICD-10 Alert

Be sure your documentation will back up claims with this red-flag diagnosis.

If your Parkinson's claim becomes caught up in Cahaba GBA's edit for the diagnosis, it will get denied four out of five times.

In an edit Cahaba used for home health agency claims with a diagnosis of Parkinson's disease, a length of stay greater than 60 days and therapy utilization of 10 or more visits, medical reviewers denied a whopping 80 percent of claims, the regional home health intermediary reports in its March newsletter to providers. The RHHI says it plans to continue the edit this quarter.

#1 reason: "The highest percentage of denials was related to medical necessity," Cahaba explains in the article about edit 5THBY. Typically the documentation didn't support a continued need for nursing or therapy visits.

Nursing visits for observation and assessment commonly go unsupported in the record. "Observation and assessment by a nurse is not reasonable and necessary where [clinical] indications are part of a longstanding pattern of the patient's condition, and there is no attempt to change the treatment to resolve them," Cahaba stresses.

Therapy visits need specific support such as objective measurements of progress. "Subjective statements such as 'walking further' or 'progressing well' do not alone support the coverage of further therapy visits," the RHHI cautions.

#2 reason: Providers often use Parkinson's as the primary diagnosis in error. "Parkinson's disease is a chronic disorder, and although it greatly affects a patient's health, it may not be the most specific skilled reason home health is currently seeing the patient," Cahaba advises. "The primary diagnosis is the chief reason for home health care and represents the most acute condition with the most intensive skilled services to be provided."

In 2007, when you coded Parkinson's in M0230, it earned 20 neuro points, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX. If you sequenced Parkinson's in M0240, no points were available in 2007.

Under the 2008 PPS refinement rule currently in effect, Parkinson's is a Neuro 2 case mix diagnosis and receives points regardless of whether it's a primary (M0230) or other diagnosis (in M0240b-f) as long as the patient also has a dressing disability noted in M0650/M0660, Selman-Holman says.

Although denials in 2008 based on a Parkinson's diagnosis may not reflect a problem with sequencing of the diagnosis, clinical documentation of both nursing and therapy must reflect skilled care for the care to be covered, she warns.

Resource: Cahaba's article, including more tips to avoid denials, is at https://www.cahabagba.com/part_a/education_and_outreach/newsletter/200803_rhhi.pdf on p. 36.