Home Health ICD-9/ICD-10 Alert

Published on Thu Jan 21, 2010 PDF

You choose your diagnosis codes based on the focus of care and the other pertinent diagnoses that impact the care you provide, but making certain you get the case mix points your agency deserves is likely always in the back of your mind.

Unfortunately, the Centers for Medicare & Medicaid Services (CMS) isn't helping matters. In the body of the OASIS User Manual, Appendix D, the CMS advises home care coders not to select their diagnosis codes based on case mix points, says Lisa Selman-Holman, JD, BSN, RN, HCSD, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done

Right in Denton, Texas. And in the M1024 instructions, CMS does not instruct coders not to use the item if no points are available.

It's only in the case scenario examples that CMS mentions that the coder would not use M1024 in certain instances because there are no points available, Selman-Holman points out.

Problem: Asking coders to determine for each episode whether a certain diagnosis should be placed in M1024 makes a somewhat difficult task even more difficult, she says.

Remember, some diagnoses get points under certain circumstances and not in others and the number of points can change based on the episode number and the patient's level of therapy utilization, Selman-Holman points out.

Suppose your patient has a fracture. You will be providing aftercare for a healing fracture. The fracture does not qualify for added case mix points because the patient doesn't have a pressure ulcer and is not receiving infusion therapy. As a result, you do not report the fracture in M1024, says Selman-Holman.

Later, the patient is recertified with a Stage II pressure ulcer. The fracture now qualifies for case mix points and you should report it in M1024, according to Medicare's comments in the Appendix

D case scenarios. But if the next episode is a later episode, the fracture will no longer qualify for case mix points, says Selman-Holman.

In the past, Medicare looked at the codes reported in M0246 to calculate risk adjustment, but now they will look to the new expanded items taking the place of M0190 and M0210 (M1010 and

M1016) as well as M1012, Inpatient Procedures, for this information, Selman-Holman says. But in the above example, there is no risk adjustment information gathered for the recertification episodes in which you don't code for the fracture, because M1010, M1016, and M1012 are not answered on recertifications, she says.

Tip: CMS refers to Table 2a in the updated OASIS documentation, but Table 2a is now Table 4 in OASIS C, Selman-Holman says.