OASIS Alert

The old saying that to assume makes a you-know-what out of 'u' and 'me' is right on the money when it comes to diagnosis coding.

Home health agencies should never make assumptions about a patient's diagnosis, urges Sue Prophet with the American Health Information Management Association's coding policy and strategy committee. Agencies must rely on a physician's documentation when coding for a patient, or face possible downcoding from their fiscal intermediary.

Assumptions about diagnosis coding seem to be at the root of many agencies' trouble with coding for patients with urinary incontinence. HHAs often incorrectly use the diagnosis "neurogenic bladder with cauda equina syndrome" (ICD-9 code 344.61), according to regional home health intermediary Cahaba GBA's March 1 issue of Medicare A Newsline.

"Spinal cord problems must be documented and clearly evident in the beneficiary's medical history for this diagnosis to be appropriate," Cahaba states. Neurogenic bladder snags many HHAs because the doc's documentation often will say only urinary incontinence, but the clinician will assume the patient has a neurogenic bladder, Prophet says.

Because neurogenic bladder is a "dysfunction of the bladder related to some underlying nervous system problem," some nurses will assume that any patient with one of these problems (for example, multiple sclerosis) who also suffers from urinary incontinence must have a neurogenic bladder, Prophet tells Eli. Even if the patient has a neurogenic bladder, the agency must have documentation from the physician to support that claim.

And to use code 344.61, the physician's documentation must note that the patient actually has cauda equina syndrome, Cahaba makes clear.

HHAs also must approach diagnosis coding differently for patients receiving treatment for many aspects of a neurological disease as opposed to those receiving treatment for just one problem associated with the disease, Cahaba notes in its Jan.1 Newsline.

If your agency is treating only one aspect of the disease, such as neurogenic bladder for an otherwise stable MS patient, you should use the general neurogenic bladder code (596.54) as the primary diagnosis, according to the RHHI. However, if you're treating multiple aspects of the disease, you can use the MS code (340) as the primary diagnosis, Cahaba says.

And that will gain you an extra 20 points in the clinical severity domain.

The fact that agencies are being tripped up by the code for neurogenic bladder with cauda equina syndrome in particular leads consultant Joan Usher to believe that part of the problem is carelessness when looking up the code.

"They're just running their finger down a little too far" in the ICD-9 coding manual, says Usher, president of JLU Health Record Systems in Pembroke, MA. "They're probably trying to code neurogenic bladder having to do with the MS patient, and they're just looking it up wrong," she offers. The code for neurogenic bladder with cauda equina syndrome is the last one listed under the heading "neurogenic bladder." That code tends to "jump off the page" more than the 596.54 code, Usher notes, "because it's at the end of a sentence, versus the other one, which is indented a little bit."

To eliminate simple errors like this one, coders should just slow down and pay special attention to what they're looking at in the book, Usher counsels.

The Centers for Medicare & Medicaid Services offers the following case study example in its coding guidance of how to approach diagnosis coding for a patient with MS who requires home care for management of a Foley catheter:

"Diagnosis 'representing the most acute condition and requires the most intensive services': Foley catheter care for bladder problem secondary to multiple sclerosis."

"A 56-year-old woman with multiple sclerosis for the past 30 years has decreased visual acuity and some impaired mobility, balance, and fine motor control, all of which have been relatively stable in recent months. She requires home health care for the management of her neurogenic bladder, which is causing urinary retention and is managed with a Foley catheter. A nurse comes every three to four weeks to change the catheter, perform other care associated with the Foley catheter, and monitor her for signs of urinary tract infection."

"ICD-9-CM coding: 596.54, neurogenic bladder; 340, multiple sclerosis, V53.6, Foley catheter change."

"Discussion: Use primary diagnosis of 788.20, urinary retention, if physician does not diagnosis neurogenic bladder. Use primary diagnosis of 340, multiple sclerosis, if the patient is being seen for more than one aspect of this chronic condition."

Editor's Note:
Cahaba's Jan. 1 Newsline is at www.iamedicare.com/Provider/newsroom/newslines/2002/010102.pdf.
The March 1 Newsline is at www.iamedicare.com/Provider/newsroom/newslines/2002/030102.pdf.
CMS' coding guidance is at www.hcfa.gov/medicare/hhmain.htm, scroll down to "Home Health PPS Policy Issues and Regulations," and click on "Correct Diagnosis Coding Practices."