OASIS Alert

If your nurses consider the bottom line when making diagnosis coding decisions, you could bottom out on your next survey.

Upcoding remains a major government focus under the prospective payment system, and choosing the wrong primary diagnosis is an easy way to find yourself in trouble, explained Pat Sevast, speaking at a recent Eli teleconference, "Mastering the Basics of Home Health Coding."

Because ICD-9 codes originally were used for statistical research, home health agencies haven't had to worry about accuracy in the past, even preferring that a code "not be too specific," said Sevast, a consultant with American Express Tax & Business Services in Timonium, MD.

But now ICD-9 codes used to answer OASIS questions M0230 and M0240 affect the case mix weight and are part of the calculation for the home health episode payment rate, she reminded listeners, and the feds are scrutinizing them. This means codes have to be both valid having the right number of digits and accurate in reflecting the patient's condition, she added.

"The regulations now require that what the clinician listed on M0230 and M0240 of the OASIS assessment must be exactly what is reflected on the plan of treatment [Form 485] and on the billing information," Sevast cautioned. They also must be in the same sequence.

Sevast offered these tips for choosing the correct primary diagnosis code:

1. Never consider the point value toward reimbursement when choosing the primary diagnosis. This will cause you trouble with feds who already suspect providers of manipulating the system.

2. Choose for the primary diagnosis the one that "is most related to the current home health plan of care." It may not be the reason the patient was admitted to the hospital, or the most obvious recent medical problem.

3. The primary diagnosis follows from the OASIS assessment. First assess the patient to determine "which body systems are normal and abnormal ... and then which of the abnormalities are problematic," Sevast advised.

You'll need to address the problems and each is likely to be linked directly to a diagnosis. Then list them in order of priority, she explained. This process can't really be done until the end of the OASIS assessment.

4. When a patient has multiple medical problems and is being treated by multiple disciplines, your primary diagnosis usually reflects "the highest level of acuity" as listed from 0 to 4 in M0230 and M0240, Sevast said. Then the others are listed in order of descending priority.

5. If you're still confused, make sure every problem addressed in the plan of care is linked to a medical diagnosis. Then ask "what requires the most intensive level of service," Sevast guided. If the patient is receiving multiple treatments, assign each one to the appropriate diagnosis to see which diagnosis has more treatment, she suggested.

6. Look at the frequency of the visits to see which diagnosis is receiving the most attention in the home health treatment plan. Don't stop with the primary diagnosis. You must list all pertinent diagnoses "relevant to the care plan," Sevast instructed. Surveyors may expect to see a diagnosis relevant to every intervention in the care plan, she warned.