Home Health ICD-9/ICD-10 Alert

Clarification is an ongoing struggle.

If you've been wondering how to code stroke patients admitted to home health episodes now that Oct. 1 has passed, you're not alone.

Agencies are still struggling with the coding changes that recently took effect, including a significant change in coding cerebrovascular accidents (strokes). The old diagnosis code for strokes - 436 (Acute, but ill-defined, cerebrovascular disease) - now specifically excludes CVAs and points coders to the 434 code series for various CVA diagnoses (see Eli's Home Health ICD-9 Alert, October 2004).

This change only added to the confusion about whether home care coders could use acute CVA codes or were required by coding guidelines to use late effects CVA codes (438 series) once the patient leaves the acute setting.
 
In the original OASIS instructions, the Centers for Medicare & Medicaid Services assigned code 436 a case mix weight that added points to the episode payment. CMS told agencies they could use acute CVA codes, even in the home setting, as long as the patient was making progress with rehabilitation, and had not been discharged with goals met.

Issue: Home health agencies changed coding practices in October 2003 to comply with the rules of the Health Insurance Portability and Accountability Act, which requires them to adhere to ICD-9 coding guidelines. One of those guidelines is that acute CVA codes are reserved for initial treatment in the hospital, according to the American Health Information Management Association. Ever since then, agencies have been wondering what to do about CVAs.

Bottom line: CMS will update its guidance to reflect the new codes and will continue to allow agencies to use acute CVA codes in the home setting, a CMS official now says.

Here's what CMS has to say in a Nov. 15 written answer to a request for clarification of CVA coding from Josephine Sienkiewicz of the Home Care Association of New Jersey: Even with the change from ICD-9 code 436 to 434.91 or related codes, the exception CMS granted HHAs, allowing them to use acute CVA codes, still holds. The 434 codes are already included as case mix codes, the official explains.

"Because the grouper does not give points to 438 we will continue to issue the guidance on CVA and strokes that was originally published in the 'Diagnosis Coding for Medicare Home Health Under PPS' as a business decision," the CMS official says.
 
CMS plans to update the guidance "to reflect the appropriate utilization of code categories 430 to 435 instead of code 436," the official continues.
 
Sienkiewicz's request for clarification contained sections excerpted from the guidance and clearly showed the need for CMS to provide further information, she tells Eli. The agency responded very quickly, she adds.
 
Snag: Agencies that are part of intermediary Palmetto GBA's service area are reluctant to rely on anything but an official statement from CMS, says Ida Blevins with Springfield, IL-based St. John's Hospital Home Health Services.
 
When asked about CMS' acute CVA coding exception at its 12-State Coalition Meeting on Jan. 9, Palmetto insisted it had "not received information that CMS has provided an exemption for coding CVA claims under HIPAA requirements" and instructed agencies to use the official ICD-9-CM coding guidelines.