Home Health Coding and OASIS Expert

Accurate coding takes more than just looking up a code in a book.

Overall, there are no earth-shattering changes among the Centers for Medicare & Medicaid Services’ updates to the OASIS Guidance Manual. But CMS’s description of the coder’s role is one change in the manual that has piqued the interest of industry experts.

As was the case previously, the assessing clinician is responsible for determining the patient’s primary and secondary diagnoses “based on the findings of the assessment, information in the medical record, and input from the physician,” CMS says in the updated manual.

But CMS goes on to say “The assessing clinician can enter the actual numeric ICD-9-CM codes for each diagnosis listed in Column 1 and 2 of M1020 and M1022, once the assessment is completed and the diagnosis is entered in Column 1. Alternatively, a coding specialist in the agency may enter the actual numeric ICD-9-CM codes in Column 2, as long as the assessing clinician has determined the primary and secondary diagnoses in Column 1.”

“CMS emphasizes that the assessing clinician should choose the primary and the secondary diagnoses and the coder can assign the codes,” says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR — Coding Done Right in Denton,Texas. “Assessing clinicians need assistance determining what should be listed in my experience,” she says. “Clinicians newer to home care or those jaded by years of CMS changes are just trying to get through answering the OASIS items correctly, and when it comes to interpreting their findings, they’re not sure what’s going on. A complete assessment, then interpretation of the findings and development of the plan of care is necessary to determine what diagnoses should be listed. It’s a higher level of skill just choosing the diagnoses and then you need the expertise of coding on top of that.”

“This is such a simplistic view of coding,” laments independent contractor Marti Holthus, HCS-D, COS-C, who works as a coding analyst for Acucare Health Strategies in Reston, Va. “It makes it sound like all you have to do is look up the code in a book. If that’s all it was, why would that require a ‘coding specialist?’”

With everything else on their plates, it’s a tall order to expect clinicians to also be coding experts. Accurate coding requires more than just access to a coding manual. At the very least, agencies should have a coding go-to person who reviews coding choices and keeps up with coding requirements.

“Coding is a specialized skill that requires years of training and practice in gleaning and interpreting relevant information from the documentation,” Holthus says. “Something as simple as using ‘and’ versus ‘with’ can change the code selection.”

“A skilled home health coder knows how to sequence diagnoses appropriately so that it paints a picture of that patient’s current health status and supports the plan of care to treat those conditions,” Holthus says. “Also, another key component to coding is determining relevant information in a patient’s medical record which is often complex and at times confusing.”

Avoid these Coding Stumbling Blocks

For the greatest coding accuracy, it’s essential for the clinician to collaborate with a trained coder as they determine the primary and secondary diagnoses and develop their plan of care, Holthus says. Coders can help clinicians steer clear of these common mistakes, she says:

• Listing symptom diagnoses when the underlying cause is known.
• Not listing relevant historical diagnoses that will or could impact care.
• Listing resolved conditions.
• Assuming some conditions are resolved just because the patient was released from the hospital.

For example: Suppose your patient was hospitalized with Sepsis, but this condition is resolved by the time the patient comes home. The patient is receiving physical therapy to treat residual weakness. It’s not appropriate to list a Sepsis code as the primary diagnosis for this patient because it is a resolved condition, Holthus says.

If coders had to assign the codes to the diagnoses listed by the clinician and nothing more, coding accuracy would suffer and would not reflect the patient’s current health status, Holthus says.

Establish a Strong Coding Policy

With CMS’ renewed emphasis on the clinician’s responsibility for diagnosis selection and sequencing, agencies will need to make certain their correction policies and processes for entering diagnoses are clear, Selman-Holman says.

Tip: Make certain your coding policy outlines how coders and clinicians will collaborate to identify the most accurate diagnosis codes and sequence them to best reflect the impact of the patient’s conditions on the home health plan of care. Ensure that the coding provides a complete picture of the patient and his need for skilled services. (See the article on page 20 for more on establishing a coding policy.)