OASIS Alert

Published on Mon Nov 17, 2003 PDF

That means you'll likely lose money if you don't know the ropes.

Downcodes will cost you when documentation doesn't support your choice of DM as primary.

The OASIS item most responsible for downcoding (reducing payment by putting an episode in a less severe category) is M0230 - primary diagnosis, says regional home health intermediary Palmetto GBA on its Web site. Downcoding occurs when the documentation in the clinical record doesn't support the OASIS answers, Palmetto notes.

From January through March, 57 percent of Palmetto downcodes were due to M0230 - and 49 percent of the incorrect codes were for diabetes, the RHHI says. "In these cases, the diabetes was stable and the skilled nurse was actually visiting the patient to provide other services," the intermediary claims.

Agencies are eager to obtain favorable reimbursement, so knowing that a primary diagnosis of diabetes is reimbursed at a higher rate may account for some of the inaccuracy, experts say. But the complicated nature of diabetes also is responsible, says consultant Kathy Greene with Tampa, FL-based Healthcare Quality Solutions.

For example, clinicians know diabetes causes blood sugar level fluctuations that can interfere with wound healing, so when a patient has a surgical wound and diabetes, the clinician may consider diabetes management a primary focus of home care, Green posits. But if the patient is skilled in managing the diabetes, the care may actually involve little or no attention to diabetes - and the record will reflect this, she adds.

If the nurse is providing diabetes management in such a scenario, the record should show timing of visits to coincide with blood sugar testing, phone calls to the physician, adjusting medication dosage and other evidence of care provided, Green notes.

TIP: When choosing the primary diagnosis, consider medications, treatments and procedures ordered, Palmetto suggests. Make a list of tasks you plan to perform in caring for this patient and consider which diagnosis each relates to, Green recommends. The one with the most tasks is likely to be the primary diagnosis.

Follow CMS' Example 

In new case examples recently published to illustrate the correct use of V and E codes, the Centers for Medicare & Medicaid Services discusses a patient discharged to home care after hospital treatment for asthma. The patient also has mild senile dementia, hypertension and stable type-two diabetes. The nurse is to teach the patient and family to use a nebulizer with medication and a spirometer to better control the asthma, ensure compliance with medication for hypertension and diabetes and monitor the patient's blood glucose record because she will be using an inhaled corticosteroid.

CMS' recommended diagnosis coding includes M0230(a) 493.00 (extrinsic asthma); M0240(b) 290.0 (senile dementia, uncomplicated); M0240(c) 250.00 (diabetes mellitus without mention of complication); M0240(d) 401.9 (essential hypertension, unspecified). M0245 is not used since the primary diagnosis is not a V code or case mix diagnosis, CMS explains.

Senile dementia is the first secondary diagnosis because it "more strongly influences the overall treatment plan," CMS says. And even though the diabetes requires glucose and medication monitoring, it isn't the main reason for home care and so is lower on the list, the discussion explains.

Uncontrolled Diabetes Requires Doc's Input 

Code sequencing may be another source of M0230 errors involving diabetes. If diabetes management is the focus of the home care, it is clear that it belongs as the primary diagnosis, experts say. But if a manifestation of the diabetes is the focus of care - such as a diabetic foot ulcer - coding guidelines mandate coding diabetes first and the manifestation second, explains consultant Joan Usher with JLU Health Record Systems in Pembroke, MA. So you might see 250.8x (filling in the appropriate fifth digit for x) followed by 707.9 (chronic ulcer of unspecified site)

And coding is required for each manifestation the patient has. The codes can't all be lumped together, warns coding expert Prinny Rose Abraham with HIQM Consulting in Minneapolis. Often people use 250.8 (diabetes with other specific manifestations) if the patient has a number of complications of diabetes, such as neurological, renal or peripheral vascular problems. But coding guidelines require you to use additional codes specific to the various manifestations, even if you don't think you need it for the bill, Abraham emphasizes.

TIP: Diabetes is either complicated or not. Diabetes disagreement is one common mistake a reviewer checking for coding accuracy should have on her list, Abraham says:

It's incorrect to code 250.0 (diabetes with no complications) with any of the other 250 codes (diabetes with various complications). Read the instructions that accompany those codes - even if you think you're familiar with them - to be sure you're using these codes accurately, Abraham suggests.

Also, diabetes is coded as either controlled or uncontrolled. Just because the patient's blood sugar is elevated doesn't mean the diabetes is uncontrolled, according to quality improvement organization Mountain-Pacific Quality Health Foundation. There are other explanations for increased blood sugar, such as recent exercise. Diabetes is coded as uncontrolled only when the physician documents it as such, the foundation explains in its Web site coding questions and answers. Often the coder will need to question the physician about this issue and about the type of diabetes, experts say.

Editor's Note: CMS' case examples are at www.cms.hhs.gov/providers/hhapps/diagnosis.pdf.