Medicare Compliance & Reimbursement

Everyone knows it's the physician and not the home health agency that officially diagnoses a patient, but the Centers for Medicare & Medicaid Services may have taken that delineation a step too far at the OASIS Coordinators Conference earlier this month.

HHAs should check with a patient's referring physician every time they choose an ICD-9 diagnosis code to represent the patient's primary and secondary diagnoses, a CMS official told attendees at the conference that brought together state officials and agency executives for intensive OASIS training. Plus, CMS wants specific documentation of that consultation over the codes that HHAs enter in OASIS items MO230 and MO240, the official added in an April presentation.

Agency attendees were incredulous at the instruction and wasted no time letting CMS know it. Such a requirement would harass physicians, who aren't particularly well-versed in ICD-9 coding guidelines anyway, and would significantly burden HHAs, attendees protested.

Attendees became even more agitated when the CMS official insisted that HHAs have always been required to go to such lengths. "This has not been the routine expectation or practice in the past," says OASIS expert Linda Krulish with Redmond, WA-based Home Therapy Services.

Coding veteran Joan Usher with JLU Health Services in Pembroke, MA says she has never heard of a home health requirement to verify the specific ICD-9 code with physician.

In situations where the physician has failed to provide a diagnosis upon referral, the agency should confirm it with a verbal order, Usher tells Eli. But generally the physician receives the plan of care with the ICD-9 code already on it based on the narrative description of the diagnosis she's provided.

Also, running specific diagnosis codes past docs is an appropriate strategy when "the agency believes a diagnosis other than the one provided at intake is appropriate - based on the comprehensive assessment," Krulish offers.

But asking for physician verification of the ICD-9 codes for every case, every time is unnecessary, not required by regulation and unfair to HHAs, experts insist.

Agencies really should view CMS' instruction "as a means by which an agency could demonstrate compliance," not a mandate to do it every time, Krulish believes.

HHAs should have more information on the possible requirement soon. After the controversy and discussion caused by the instruction at the conference, CMS says it will issue a clarification on the matter.