Home Health Coding and OASIS Expert

Don’t overlook your correction process.

Your agency’s ICD-9 coding policy ensures accuracy, consistency, and compliance between coders. Make sure your agency’s policy promises to:

1. Adhere to coding guidelines. You can’t code correctly if you don’t follow the ICD-9-CM Official Guidelines for Coding and Reporting. Your policy should acknowledge that it’s necessary to follow these guidelines.

Essential: Following the guidelines means you commit to coding to the highest level of specificity and avoiding non-specific codes.

2. Check documentation. Make sure your coding policy outlines your intention to obtain source documents from the physician, hospital admission or discharge summaries, and verification with the physician of diagnoses.

Essential: Be sure to indicate your plan to ensure that the diagnosis codes you report are consistent with the information in the medical record including the comprehensive assessment and the plan of care. Also describe your plans for coder/clinician collaboration.

3. Make corrections. Document your process for correcting diagnosis code errors. Include steps to ensure diagnoses match on the assessment, the plan of care, and the billing form.

4. Maintain quality. Describe your quality improvement plan. Include plans for sample record review on a regular basis to validate the accuracy and consistency of coding. These reviews should ensure that diagnoses are supported by documentation, that coding is consistent with the plan of care and the assessments, that the physician verifies all diagnoses, and that coding follows official guidelines.

5. Provide education. Describe your plans for keeping coding staff up-to-date with coding changes. And don’t miss the opportunity to outline the coder’s role in educating staff about coding guidelines and use of diagnosis codes.