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Home Health ICD-9/ICD-10 Alert

READER QUESTIONS:

Set Significant Changes Straight

Published on Wed Apr 22, 2009

Question: I'm having some trouble reconciling coding for a significant change in condition (SCIC) with what our biller says she needs. For example, we were caring for a patient's hypertension when she developed an ulcer. The hypertension was under control, and our focus of care shifted to the ulcer, so I completed a SCIC assessment. Our biller says that because the diagnosis on the SCIC (the ulcer) does not match the diagnosis on the OASIS SOC (the hypertension), she cannot bill for our services. If this is true, what is the point of completing the SCIC?

-- Oregon Subscriber

Answer: A "SCIC" assessment is actually referred to as an "Other Follow-Up" assessment in the regulations. The regulations require that the agency perform an update to the comprehensive assessment when there is a major decline or improvement in the patient's condition. The Conditions of Participation require that the agency define a major decline or improvement that triggers an update to the comprehensive assessment.

These assessments became known as SCIC assessments in the old PPS. In the PPS prior to January 2008, if a patient had a significant change in condition, an "other follow-up assessment" or sometimes a Resumption of Care (ROC) could result in a higher payment and the agency had the option of billing the higher home health resource group (HHRG). In the PPS Refinement Rule, effective Jan.1, 2008, this opportunity for billing a higher HHRG no longer exists.

The requirement to perform the update to the comprehensive assessment is still there in the CoPs.The coding on an "Other Follow-Up" and most ROCs does not impact billing. The coding on a ROC impacts your risk adjustment and sometimes impacts your billing, if performed in the last five days of the episode.

Your biller may bill the episode with the HHRG established with the SOC. There is no way to bill for the higher cost of the ulcer in this case until the patient is recertified.

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