Home Health Coding and OASIS Expert

Beware of coding based on OASIS responses.

When your patient has a psychiatric condition, it can impact the care you provide as well as the reimbursement your agency receives. But listing a psychiatric diagnosis inappropriately can have a negative impact for both the patient and your agency. Consider these five tips before reporting a psychiatric diagnosis.

Tip # 1: Consider the impact before you code. You need to be careful when assigning psych codes because there’s a social stigma to these diagnoses, says Sparkle Sparks, PT, MPT, COS-C, HCS-D, AHIMA Approved ICD-10-CM Coding Instructor with Redmond, Wash.-based OASIS Answers. “Be careful to assign the right codes for the right reason,” she says. “How would you like to have a psych diagnosis for a condition you don’t really have in your medical record? It can cause insurance denial and even have unanticipated legal ramifications.” 

“We have an obligation to the patients whose medical records we’re dealing with,” Sparks says. “These diagnoses follow the patient forever. We have a responsibility to be accurate.”

Tip #2: Know where not to look for documentation. Before you list a code for a psych condition, it’s important to make sure the diagnosis is documented in the medical record and/or referral information from the physician, points out Teresa Northcutt, BSN, RN, COS-C, HCS-D, AHIMA Approved ICD-10-CM Trainer with Denton, Texas-based Selman-Holman & Associates.

“You can’t code a psych diagnosis based just on medications or statements from the patient or caregiver,” Northcutt says. “This is true for all diagnoses, but especially important for psychiatric conditions. You don’t want to be responsible for an unsubstantiated psych diagnosis showing up in a patient’s medical record!”

Tip #3: Look for support from the plan of care. Even if your patient has a physician-documented psychiatric diagnosis, including a code for the condition is not always appropriate. If you’re not addressing it, it’s not causing you to provide different care, or impacting the patient’s ability to recover, then why are you coding it? 

Look to the plan of care (POC) orders to support your decision to code for a psychiatric condition. If you’re considering including a psych diagnosis, look to the POC for interventions for assessment of patient’s mental status and mood, compliance with medications and treatment regimen, response to medications and treatment, instruction on medications, treatment, and signs and symptoms of complications to report, Northcutt says. “If there are orders for a psychiatric nurse, those specific interventions should also be included in the POC. Don’t overlook safety measures and goals related to the patient’s psychiatric condition,” she adds.

Documentation for psychiatric conditions should be directed at the management and treatment of the disease process, agrees J’non Griffin, RN, MHA, WCC, BCHH-C, HCS-D, COS-C, AHIMA Approved ICD-10 Trainer/Ambassador, Senior consultant with Home Health Solutions in Carbon Hill, Ala.

Tip #4: Don’t code based on OASIS responses. If your patient shows a positive depression screen in M1730 — Depression Screening, that doesn’t mean it’s appropriate to list a diagnosis code for depression. The physician must confirm the diagnosis before you can include it in the list of diagnoses.

Just because you identify apparent anxiety issues or depression characteristics on the OASIS, doesn’t mean you can automatically assign a psych diagnosis, Sparks agrees. “That’s the difference between observing something according to the OASIS versus the patient really having a psych diagnosis,” she says. 

Conversely, if the patient has a confirmed diagnosis of depression, but scores a zero on M1730 — Depression Screening, that doesn’t necessarily mean you wouldn’t include depression in your list of diagnoses, 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. The patient may be feeling better because of the medications or other treatments, however interventions such as compliance with medications and treatment regimen, response to medications and treatment, instruction on medications, treatment, and signs and symptoms of complications to report are still appropriate, she says. “It is fairly typical for patients with depression to stop their medication when they begin feeling better.” 

Bottom line: “A diagnosis of depression can only be made by the patient’s physician — not a home health clinician based on findings from a screening tool,” Northcutt says.

Tip #5: Know where to find your codes. In your ICD-9 coding manual, you’ll find psychiatric conditions in several chapters including: 

5 — Mental, Behavioral and Neurodevelopmental Disorders
6 — Diseases of the Nervous System and Sense Organs
16 — Symptoms, Signs, and Ill-defined Conditions
17 — Injury and Poisoning.