Home Health ICD-9/ICD-10 Alert

Hint: Focus on the patient

If your claims are being downcoded for incorrect diagnosis codes, your agency could be losing thousands
of dollars.

Even now many clinicians don't understand coding or how to select a primary diagnosis. It will take time to get it right, says consultant Melinda Gaboury with Nashville, Tenn.-based Healthcare Provider Solutions. Coding accuracy requires clinical and financial staff to work together.

Strategies: Follow these tips to avoid case mix errors:
 
1. Understand the primary diagnosis

Home health rules define primary diagnosis as "that diagnosis which represents the most important reason you're providing home care, the most acute diagnosis and that which justifies the intensity of service," says Pat Sevast with American Express Tax & Business Services in Timonium, Md. You can't just call the physician for a diagnosis, experts say.
 
2. Don't simply repeat the hospital diagnosis

Clinicians still put acute fracture codes in M0230 and M0240, but they are not treating the acute fracture at home, even if the patient did not have the fracture repaired, Gaboury says. 
 
3. Focus on the patient, not on the points

If you are in the home to manage new medications and fluid intake problems in a diabetic patient who developed congestive heart failure, the primary diagnosis is most likely the CHF (which gives you no case mix points) rather than the diabetes (which gives you 17 points), Sevast says.

4. Mind your manifestation codes

Manifestation codes can never be used as a primary diagnosis, but to count in the case mix adjuster, they must be the first secondary diagnosis "and include all the digits the coding rules require," says coding expert Sue Prophet, director of coding policy and compliance at the American Health Information Management Association. 

Example: An agency providing care primarily for a diabetic ulcer on the heel would code a primary diagnosis of 250.8x (Diabetes with other specific manifestations) followed by a first secondary diagnosis of 707.14 (Ulcer of heel and midfoot).

5. Know your ulcers

If you plan to code the primary diagnosis as diabetes with a manifestation code for the foot ulcer, "absolutely be sure you have documentation that it is a diabetic ulcer rather than a pressure ulcer or stasis ulcer," Sevast says.

6. Determine if a V code displaced a case mix 
 
If you use a V code as a primary diagnosis, you can't stop there, or you may lose money you deserve, experts say.

Now that V codes can be the primary diagnosis, you must select the diagnosis code "that would have been reported as the primary diagnosis under the original OASIS-B1 (8/2000) instructions that did not allow V codes," the Centers for Medicare & Medicaid Services states. If that code is a case mix code, it goes in M0245 so it can be calculated into the case mix adjustment.

7. Ask yourself the same questions that your RHHI will ask

1. Did you select the correct primary diagnosis, and 2. Does the record support this diagnosis? To prevent downcoding, focus on the care plan, the acuity of the diagnosis, and the justification in the record.