Home Health ICD-9/ICD-10 Alert

Question: Our agency has a tendency to downcode a lot. When I questioned this practice, I was advised that there is nothing to worry about because the agency tends to downcode a lot more than upcode. They seem to think that sooner or later our regional home health intermediary (RHHI) will catch the downcoding and reimburse the money that the agency is entitled to. Is this correct? Are there any repercussions of this practice?

Answer: Your RHHI will not give you any money back that you might be due as the result of downcoding. The only way they would catch downcoding would be through medical review, and the fiscal intermediaries tend to leave agencies that are not costing them lots of money alone.

Although it's important not to upcode because you could face possible medical review and accusations of abuse, downcoding isn't the answer. Medicare chose the diagnoses that contribute to the case mix score because caring for those diagnoses is more costly for home care agencies.

By downcoding you are not getting the money you are entitled to under the prospective payment system. Downcoding also results in your agency not getting the risk adjustment you deserve on outcomes.

With the new PPS looming in the near future, it will be even more important to have competent home care coders on staff who understand sequencing and the appropriate use of V codes.