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Home Health ICD-9/ICD-10 Alert

Prospective Payment System:

Prepare For Major Stroke Coding Changes Under New PPS

Published on Sun Aug 12, 2007

Are you overusing abnormality of gait?

The proposed changes to the prospective payment system (PPS) rule will make a big difference in the way your case-mix points are calculated. But the changes the Centers for Medicare & Medicaid Ser-vices (CMS) has suggested for some of home care's most frequently reported codes have even the experts scratching their heads.

Stay on top of these developments to see how your agency -- and your reimbursement -- might be affected.


1. Adjust your stroke coding to reflect 434.91 change.

The proposed case-mix diagnosis list includes 436 (Acute, but ill- defined, cerebrovascular disease), a code home care stopped using some time ago.

Old way: Home care coders used this code to report an acute, but ill-defined stroke until about three years ago when the ICD-9 Coordination and Maintenance Committee indicated that 434.91 (Cerebral artery occlusion, unspecified; with cerebral infarction) was the more appropriate code, says Judy Adams, RN, BSN, HCS-D, with LarsonAllen in Charlotte, NC.

New way: But in the proposed rule, 434.91 is no longer included as a case-mix code for stroke, Adams points out. "Code 434.91 is the most frequent stroke diagnosis used by home health agencies and under the current case-mix system earns 20 neurological points," she says.

Under the proposed rule, 434.91 would no longer afford any case-mix points, even when it's listed as the primary diagnosis. This is true even though more specific codes in the same category are included, such as 434.11 (Cerebral embolism; with cerebral infarction).

These stroke coding case-mix changes have raised many questions. "Was this a mistake, or is home health now going to be instructed to use the late effects of the CVA code category (438) as is used in other health-care facilities?" the Visiting Nurse Associations of America (VNAA) wondered in a PPS rule comment letter to CMS. (Look for the answer to this question in next month's issue.)

In its letter to CMS regarding the proposed changes, the National Association for Home Care & Hospice (NAHC) asked CMS to "proceed with caution before making changes to the proposed PPS diagnosis list" and "provide guidance on proper diagnosis coding and support appropriate diagnosis coding practices." NAHC also requested that CMS remove code 436 from the list of case-mix diagnosis codes and add 434.91 in accordance with current diagnosis coding guidelines.


2. Keep chronic ulcer code 707.9 in the mix.

Another questionable proposed case-mix diagnosis is the code 707.9 (Chronic ulcer of unspecified site). This code has been jokingly referred to by some coders as the "patient has an ulcer but you don't know where it is" code. Intermediaries routinely return to provider (RTP) claims listing 707.9, so it's odd that it made the proposed list, say experts.


3. Beware of gait coding abnormalities.

Abnormality of gait code 781.2 is still a case-mix code, Adams notes. But when you look at how the points for this diagnosis are assigned, you'll only get credit when it's linked with either a pressure ulcer or therapy, she says.

The proposed rule states that a patient must have a pressure ulcer to receive a case-mix adjustment for the diagnosis of abnormality of gait, NAHC notes in its letter to CMS.

But the abnormality of gait diagnosis often indicates patients in need of therapy services for gait training. These are not typically bed- or chair-bound patients and, therefore, do not typically have pressure ulcers, NAHC says. NAHC requests that CMS reevaluate the impact of the combination of abnormality of gait and pressure ulcers on resource utilization, or provide the rationale for the linking.

Red flag: Use of the abnormality of gait (781.2) diagnosis increased 50 percent between the home health interim payment system (IPS) period and the early years of PPS, Cindy Krafft, MS, OPT, with UHSA said during a recent Eli audioconference.

"Apparently, we're reaching some kind of plague condition where all of our patients are suddenly acquiring this illness," Krafft joked. The intent of the diagnosis codes selected to factor into reimbursement was to indicate that these particular patients were not your typical home health patients, she said. Patients with these conditions would require additional resources, so the system made these additional resources available, she said.

However, it appears home care has been trying to put as many patients as possible into these case-mix point-related diagnosis groups, and Medicare has to question that, Krafft said.

The bottom line: Overuse of diagnoses like abnormality of gait makes it difficult to pinpoint what's really wrong with homecare patients.

Note: CMS revealed the final PPS rule just as Home Health ICD-9 Alert went to press. Watch for the details on the final changes and how they will affect your agency in next month's issue.

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