Home Health ICD-9/ICD-10 Alert

Get the details on these diagnosis coding cuts.

Losing several of the codes the Centers for Medicare & Medicaid Services plans to drop from the case mix list may not have a big impact on ­your agency’s reimbursement. But the changes suggested in the 2014 home health prospective payment system proposed rule are still raising eyebrows.

Background: CMS’ “clinical staff along with clinical and coding staff from Abt Associates (our support contractor) and 3M (our HH PPS grouper maintenance contractor), recently completed a thorough review of the ICD-9-CM codes included in our HH PPS Grouper,” CMS explained in the home health prospective payment system proposed rule published in the July 3 Federal Register. “As a result of that review, we identified two categories of codes, made up of 170 ICD-9-CM diagnosis codes, which we are proposing to remove from the HH PPS Grouper, effective January 1, 2014.” (Read more about the proposal in Home Health ICD-9/ICD-10 Alert v10, n10.)

Many of the proposed case mix changes won’t make a difference “because we were only using them as the reason for aftercare,” says Judy Adams, RN, BSN, HCS-D, HCS-O, with Adams Home Care Consulting in Asheville, N.C. Effective this year, CMS will no longer award case mix points for resolved diagnoses so these diagnoses aren’t being reported as frequently, Adams explains.

But there are many diagnoses on CMS’s proposed list that HHAs continue to treat, Adams says. It appears that CMS chose certain words to cue off of in making the cuts, but the current ICD-9-CM codes available do not offer other alternatives for reporting these types of conditions, she says.

For example: CMS proposes cutting several chronic ulcer codes in the 531.x (Gastric ulcer) category. With codes like 531.40 (Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction) “CMS obviously considers the word hemorrhage as ‘too acute’ for home health,” Adams says. But while the patient is not necessarily hemorrhaging at the time he is released to home health, he may still be bleeding. Or the home health agency may need to monitor and evaluate for any new bleeding such as gastric, peptic, duodenal, gastrojejunal and esophageal ulcers, she says.

Problem: “True, a patient who is actively hemorrhaging would be referred to the ER and the ACH, but, there are no codes that describe just ‘bleeding’ and this diagnosis continues until the condition is gone,” Adams says.

History repeating itself?

“In the late 1980s, the Staggers lawsuit was won in part by the fact that coverage cannot be determined based on arbitrary rules like a patient is ‘too sick’ for home health,” Adams says. “Now CMS is doing the same thing, but instead of saying they won’t cover the care, they are saying ‘we won’t pay the agency for the resources necessary to care for these patients.’”

“The removal of all of these diagnoses appears to be primarily motivated by another way to reduce reimbursement to home health care without true consideration of diagnoses that are treated in the home health setting,” Adams laments. “True, these are not part of the top 20 percent of home health diagnoses, but is that enough reason to say these codes can no longer earn case mix points?”

Diverticulitis, diverticulosis, and abscesses draw attention

There are also patients who cannot tolerate surgery and may need to be followed in home care in a subacute state, Adams says.

For example: Consider patients with diverticulitis, diverticulosis, or abscesses. These conditions may be treated while the patient is an inpatient, but she can still have some of the disease process present when she returns home.

Codes 562.02 (Diverticulosis of small intestine with hemorrhage), 562.03 (Diverticulitis of small intestine with hemorrhage), 562.12 (Diverticulosis of colon with hemorrhage) and 562.13 (Diverticulitis of colon with hemorrhage) are all slated for removal from the case mix list. Patients who have surgery for diverticulosis or diverticulitis may have the area of the bowel operated on clear, but have other areas that still have active disease process, Adams says.

Several abscess codes are also on the chopping block. Patients with abscesses may undergo incision and drainage and attempts to clean up these wounds, Adams says. But they often return home with the abscess still present and being drained with orders for the home health nurses to do packing and wound dressings.

Agencies may lose out with restless leg and anemia

Another soon-to-be-former case mix code is restless leg syndrome (333.94). This condition can be treated in home health through monitoring new medications, teaching about the condition and the medications being used, and monitoring and evaluating the effectiveness of new treatments, Adams says.

The code for sickle cell trait (282.5) is also slated to be removed from the case mix list. Sickle cell trait is a serious risk factor and HHAs that do not identify this and educate patients regarding the disease process would be providing very poor quality care, Adams says.

Post-operative anemias due to significant blood loss during surgery or just prior to surgery are pretty common in home health, Adams says. Unfortunately, 285.1 (Acute posthemorrhagic anemia) is also proposed to be dropped from the case mix list. “The anemia is still present on return home and home health nurses teach about the condition, signs and symptoms to look for and monitor for any continued bleeding, as well as educate the patient about what should be reported and nutritional steps to treat the anemia while it is resolving.” Even patients who have received blood transfusions in the inpatient setting due to these blood loss anemias do not return to normal right away, they need continued monitoring and evaluation, she says.

Over and inappropriate use of the case mix code 530.81 for GERD likely led to its planned removal from the list. When the medical record does not clearly identify why the condition is a problem for the patient and the plan of care does not show any intervention related to treating or controlling GERD, it’s inappropriate to code for it. The OIG March 2012 report particularly used GERD as an example of frequent inappropriate coding for these very reasons, Adams points out. “Removing that code was only a matter of time.”

Losing out: In addition to providing follow up care for patients with many of the diagnoses CMS plans to demote from case mix status, home health agencies also care for patients who have received some initial treatment in an acute care setting but still have the condition at discharge, Adams says. Plus, some patients are not surgical candidates and may not be able to tolerate or agree to surgical correction of these chronic problems so again home health is treating the patient in the community, she says.

If CMS goes forward with deleting these 170 codes, HHAs will need to be extra certain to answer all of the OASIS items correctly to be sure they are getting all available case mix points, Adams cautions. But don’t stop reporting these codes when appropriate. For data accuracy, “HHAs need to continue using these codes where they are appropriate to the patient situation even though they will no longer gain case mix points.”