Home Health ICD-9/ICD-10 Alert

Question: Our coder tells us that we must have a medication for each diagnosis a patient has. Is this accurate? For example, we just received a referral for a patient who needed therapy and teaching after a fall. She has a history of hypertension for which she is taking herbal remedies. She also has a tumor on her occipital lobe which is causing syncope and resulted in her recent fall. She is taking another home remedy for the pain due to the fall.

Our coder feels that she is not an appropriate home health patient because she isn't taking any prescribed medications, but she would benefit from therapy and fall precaution teaching. Must she have a medication to pair with each condition?

-- California Subscriber

Answer: There is no requirement to have a medication for each diagnosis. Assessing clinicians should document the diagnoses found, and the coder should code the diagnoses based on clinical assessment and the plan of care.

Required skilled intervention makes the patient appropriate for home health treatment, not the list of medications she is receiving.