Home Health ICD-9/ICD-10 Alert

Published on Tue Sep 27, 2005 PDF

Know when CHF belongs in M0230.

Take the time to re-think your coding strategies where diabetic patients are concerned--especially those with congestive heart failure--or you may face denials.

A probe review turned up "inappropriate use" of the primary diagnosis 250.xx leading to a widespread edit for providers served by Cahaba GBA, the regional home health intermediary announced.

The edit--topic code 5THBK--will select non-start-of-care claims that have a M0230 primary diagnosis of diabetes and a M0240 secondary diagnosis of CHF, Cahaba says in its July 26 Web posting.

Case Mix Equals Medicare Scrutiny
 
Caution: Because diabetes is a case mix code, agencies get paid more for an episode in which diabetes is the primary diagnosis. If you put 250.xx (Diabetes mellitus) in M0230 when it does not belong there, your claim will be downcoded or denied.

Many conditions are exacerbated by diabetes, but that doesn't make the diabetes primary. First ask yourself if diabetes is the most important reason you are providing home care, the most acute diagnosis and the reason for the most intense services, coding experts say.

If you're in the home to manage CHF in a diabetic patient, CHF likely belongs in M0230, not diabetes, warns Mary I. Falbo, president of Millennium Healthcare Consulting Inc. in Lansdale, PA.

Historically, diabetes is addressed in the first episode, says senior clinical consultant Judy Adams, RN, BSN, HCS-D with Charlotte, NC-based Larson Allen Healthcare Group. Subsequent episodes are more likely to address the CHF, she tells Eli.

Hidden trap: Be sure to re-evaluate the diagnosis sequencing at recertification and not just continue with the same listing as the previous episode, Adams warns.

Manifestations Can't Be Primary
 
Watch for: Mistakes occur when staff do not understand coding language, said coding expert Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates, speaking at a recent Eli-sponsored teleconference.

If your patient has manifestations of diabetes, and you look up the code for that manifestation, the instructions will tell you to "code first" the underlying diabetes.

Code first does not mean code the diabetes as primary, Selman-Holman explained. If some other condition is the main focus of the episode's home care, you still code that condition in M0230. Then when you place the diabetes manifestation code in M0240, place the 250.xx diabetes code in M0240 before the manifestation code.

Trap: One error clinicians often make is to code the diabetes as primary when the patient has a diabetic ulcer but the ulcer and diabetes are not the main focus of care. This is upcoding, and it can lead to both downcoding and fraud and abuse charges, Selman-Holman warns.

Another common error is automatically coding polyneuropathy when patients are receiving home care for insulin administration or prefilling syringes. Don't automatically assume this is the reason patients need this assistance, although it might be. Instead, the patient could have cognitive problems or late effects of a stroke that interfere with self-care, Selman-Holman notes. The medical record should reflect that the patient has poor manual dexterity due to the polyneuropathy, if that's the case, for example.

Avoid These Errors Leading To Underpayment

Other diabetes coding errors can mean your agency loses money it is entitled to, Selman-Holman warns. Watch for these common problems, she suggests:

1. Missing or wrong digit. The diabetes code must have five digits. The main diabetes category is 250. The fourth digit indicates what manifestations the patient has and the fifth digit denotes the type of diabetes and whether it is controlled or uncontrolled.

Tip: If you code 250.0x (Diabetes mellitus without mention of complication) but then code a manifestation, your claim may be downcoded for incorrect diagnosis coding.

2. Misunderstanding coding symbols. Slanted brackets in the alphabetic index indicate a manifestation, as do italics in the tabular list. A manifestation code can't be coded by itself. The underlying disease must precede it.

Warning: If you code a number of diabetes manifestations, each manifestation that is in a different category must be preceded by its specific diabetes code.  For example, if the patient has diabetic glomerulosclerosis and diabetic gangrene, you would code both 250.4x (Diabetes mellitus with renal manifestations) followed by 581.81 (Nephrotic syndrome in diseases classified elsewhere) and 250.7x (Diabetes mellitus with peripheral circulatory disorders) followed by 785.4 (Gangrene).

3. Failing to query physicians. You can't code for uncontrolled diabetes unless the physician specifically documents that diagnosis. And if the diabetic patient has an ulcer, you must have confirmation from the physician that it is a diabetic ulcer before coding for that.

Watch for: If a diabetic patient has osteomyelitis, you don't have to ask the physician if this is connected to the diabetes.

In coding, osteomyelitis is assumed to be a manifestation of diabetes, Selman-Holman says. In this situation, you would code 250.8x (Diabetes mellitus with other specified manifestations), then 731.8 (Other bone involvement in diseases classified elsewhere) followed by 730.xx for the osteomyelitis. Similarly, if a diabetic has gangrene, it is assumed to be a manifestation of the diabetes, she adds.

4. Coding diabetic ulcers inaccurately. Unlike pressure or stasis ulcers, diabetic ulcers don't get points through the OASIS wound and lesion M0 items.

If your episode focuses on a diabetic ulcer, but you put the 707.1x manifestation code in M0230, you lose 17 points and the dollars that go with them.  Instead, put the 250.8x in M0230 and 707.1x as the first secondary diagnosis, Selman-Holman explains.

Note:  The Cahaba edits are at www.iamedicare.com/provider/newsroom/whatsnew/whatsnew.htm.