OASIS Alert

Regional home health intermediaries recently have called home health agencies on the carpet for a couple of diagnosis coding problems that have resulted in claims denials.

Many agencies are running amuck with coding for the care of surgical wounds, Cahaba GBA says. The problem is a typical one: Clinicians often turn to the ICD-9 manual's chapter on injury and poisoning to code for surgical wounds. But this tactic is incorrect, because "trauma codes are reserved for use when reporting injuries sustained from accidents or from intentional violence," Cahaba explains in its most recent Medicare A Newsline. And surgery clearly doesn't fall into one of those categories.

Agencies often turn to these codes when dealing with OASIS because they face an apparent lack of a better approach to take. Even though there are V-codes for encounters for the care of surgical wounds, agencies aren't allowed to use V-codes on OASIS. "This raises a problem for coding for OASIS MO230/MO240 (diagnosis and severity index) in most post-surgical cases where care of the surgical wound is the primary reason for home care," the Centers for Medicare & Medicaid Services admits in its prospective payment system diagnosis coding guidance.

In light of this problem, agencies should code for the condition that caused the surgery leading to the wound in question when dealing with surgical wounds, notes consultant Joan Usher with JLU Health Record Systems in Pembroke, MA.

This approach confuses many clinicians, and justifiably so: "They're there to take care of the wound, it is a wound clinically, but as far as the primary diagnosis, it's not coded as a wound," Usher says.

This logic also seems counter-intuitive because in many cases, you'll end up coding for a condition the patient no longer has.

For example, a person who had an appendectomy certainly would not need home care for appendicitis in an appendix he no longer has, exclaims Sue Prophet with the American Health Information Management Association's coding policy and strategy committee. CMS also notes this problem in the coding guidance, but concludes that "nevertheless, when a patient is admitted to home care mainly for surgical wound assessment and treatment, the condition responsible for the surgery is often the only primary diagnosis available on OASIS."

The best way to train your staff to use this admittedly odd reasoning is by repetition, Usher suggests. Agencies should periodically give clinicians short quizzes giving them examples of various wounds, and ask what codes they would use in those situations.

Agencies also have trouble coding for wounds with complications, Cahaba reports. To code for a complicated wound, agencies must have supporting documentation from the physician. Clinicians should never make assumptions when coding, insists Prophet.

If a nurse believes a wound is taking too long to heal, it appears to be draining or exhibits other suspicious signs, she can't simply decide to code it as an infected, or otherwise complicated, wound. "It really has to be based on the physician's documentation that the patient has that complication," Prophet explains.

Editor's Note: To see the Medicare A News-line, go to www.iamedicare.com/Provider/newsroom/newslines/2002/030102.pdf.