Home Health Coding and OASIS Expert

Sequencing matters: List your manifestation etiology pairs in the wrong order and you’ll risk a returned claim.

Do you know how to sequence codes when the focus of your patient’s care is a manifestation? Make sure you have the guidelines down pat or you could risk being caught up in new edits.

Why? On Jan. 1, the Centers for Medicare & Medicaid Services will implement edits that will return home health agency claims that contain a manifestation code as primary. Under ICD-9 coding conventions, a manifestation code may be listed only after the code for its underlying condition.

“An analysis of Outcome Assessment and Information Set (OASIS) records and claims for CY 2011 revealed that some agencies were not complying with the coding guidelines when reporting the primary diagnosis, in particular with regards to certain codes that require the underlying condition be sequenced first followed by the manifestation,” CMS says in Change Request 8813. “Given the concerns regarding compliance with coding guidelines, CMS is adopting edits to ensure greater compliance of coding guidelines for primary diagnosis codes.”

Do this: “The principal diagnosis reported on the home health claim shall be the ICD-9-CM code that is most related to the current home health plan of care,” CMS instructs. “HHAs shall not submit manifestation codes as the primary diagnosis.”

Remember, “the patient’s primary diagnosis is defined as the diagnosis most related to the current home health plan of care,” CMS says in a MLN Matters article regarding the edits. “The principal diagnosis reported on the home health claim should be the ICD-9-CM code that is most related to the current home health plan of care. HHAs should not submit manifestation codes as the primary diagnosis.”

Know These Manifestation Coding Basics

The coding guidelines for manifestations are clear — sequence the underlying condition first, followed by the manifestation. If you follow this rule, you’ll keep your claims in the clear.

Details: The ICD-9-CM Official Guidelines for Coding & Reporting advises, “Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a ‘use additional code’ note at the etiology code, and a ‘code first’ note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.” 

You’ll find the same guidelines for reporting etiology/manifestation pairs, also referred to as “mandatory multiple coding” in your ICD-10 coding manual as well.

Why? When your patient is receiving care directed at a manifestation, to fully describe his condition, you must include a code for the etiology (or the cause) of the manifestation as well as a code for the manifestation 

(or the effect). 

In addition to “use additional code” and “code first” notes in the tabular list of your coding manual, you’ll see a specific structure in the alphabetic index for etiology/manifestation pairs. Here, both conditions are listed together with the etiology code first, followed by the manifestation codes in brackets. “The code in brackets is always to be sequenced second,” the guidelines state.

Hint: When verifying codes in the tabular listing if you see code titles with “in disease classified elsewhere,” this is a signal that you shouldn’t list the diagnosis as primary, says Joan Usher, BS, RHIA, COS-C, ACE, AHIMA-Approved ICD-10-CM Trainer with JLU Health Record Systems in Pembroke, Mass. Codes with this designation fall under the the etiology/manifestation convention and are never permitted to be used as a first listed diagnosis codes, she says. “But remember, not all manifestations have this designation,” she adds

Coding example: Your new patient was referred to your agency by her primary physician for assistance with medication adjustment for behavioral issues due to dementia related to her Alzheimer’s diagnosis. Her behavior has escalated with aggressiveness.

The focus of your care is the patient’s dementia-related behavioral issues, but when you look up 294.11 (Dementia in conditions classified elsewhere with behavioral disturbance) in the tabular list of your coding manual, you’ll notice a note at 294.1 (Dementia in conditions classified elsewhere) that reminds you to code first an underlying physical conditions, Usher points out. In this case, you’ll report 331.0 (Alzheimer’s disease) as primary in M1020a, followed by 294.11 in M1022b.

Handle Sequencing Conflicts Correctly

Suppose you are reviewing a start of care (SOC) assessment, for a patient who is receiving wound care from your agency for a chronic diabetic ulcer on the right heel. The diagnosis code in M1020 — Primary Diagnosis is 707.14 (Ulcer of lower limbs, except pressure ulcer, heel and midfoot). The corresponding etiology code 250.80 (Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled) isn’t among the codes in M1020 — Other diagnoses. You know that this is a mistake because according to coding guidelines, the manifestation code shouldn’t be in the primary diagnosis spot — the underlying etiology code should be there instead.

Question: Can you consider this situation a technical coding “error” and follow your agency’s correction policy allowing you as the coding expert to correct this error, without conferring with the assessing clinician?

Answer: No, says CMS in the Category 4b — OASIS Data Items issued in June. “If the assessing clinician identifies the diagnosis that is the focus of the care and reports it in M1020, and ICD-CM coding guidelines required that the selected diagnosis is subject to mandatory multiple coding, the addition of the etiology code and related sequencing is not a technical correction because a diagnosis is being added.”

Even when the coding for a patient is incorrect because the guidelines require you to list an additional diagnosis, you must first contact the assessing clinician and get her buy-in before adding a code.

Why? When you question the accuracy of the primary diagnosis the assessing clinician chose, the problem goes beyond being a “technical” error.

If you discuss the manifestation coding situation with the assessing clinician and she agrees that you should modify the sequence of the diagnosis codes to more accurately reflect the diagnosis that is most related to the current plan of care following current ICD-CM coding guidelines, you can make the change according to your agency policy, CMS allows.

Note: The CR is at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1405OTN.pdf. The MLN Matters article is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8813.pdf. Find the Category 4b — OASIS Data Items under OASIS Questions & Answers here: www.oasisanswers.com/aboutoas_links.htm.