Home Health ICD-9/ICD-10 Alert

Intermediary denies HHA claims with ICD-9 code 332.x.

Home health agencies can't seem to get it right when it comes to claims with a primary diagnosis of Parkinson's disease (332.x) -- and the mistakes can be costly.

Regional home health intermediary Cahaba GBA is continuing edit 5THCD, which selects claims with Parkinson's disease as the primary diagnosis, a length of stay greater than 60 days, and no billed therapies, according to Cahaba's September newsletter for providers.

Problem #1: Cahaba medical reviewers denied many of the claims caught up in the edit "because the documentation did not support the continued need for skilled nursing," the newsletter said. "To be covered as skilled nursing services, the services must require the skills of a nurse and must be reasonable and necessary to the treatment of the patient's illness or injury."

Providers must adhere to strict standards for observation and assessment to qualify for Medicare payment, Cahaba instructed. Observation and assessment "are reasonable and necessary skilled services when the likelihood of change in a patient's condition requires a skilled nurse to identify and evaluate the patient's need for possible modification in the ... Plan of Care until the patient's treatment regimen is essentially stabilized."

But don't count on fluctuating vital signs and other changes to meet that requirement. O&A "is not reasonable and necessary where these 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 said.

Problem #2: Cahaba reviewers downcoded many claims because agencies inappropriately used Parkinson's as the primary diagnosis in M0230. "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 cautioned.

Some of these downcodes are based on the previous PPS when Parkinson's disease was worth more case mix points (20) when coded as a principle diagnosis but not worth any points if it was listed as a secondary diagnosis. Under the latest PPS refinements, it doesn't matter whether Parkinson's is primary or a secondary diagnosis. As long as other requirements are met, there are case mix points are available for Parkinsons.

Cahaba's September Newsline is online at http://www.cahabagba.com/rhhi/news/newsletter/200809_rhhi.pdf.