OASIS Alert

Another wrinkle appears in stroke coding.

If you've been wondering what happens to the stroke case mix code, now that Oct. 1 has passed, you're not alone.
 
Agencies are still struggling with the coding changes that recently took effect, including a significant change in coding cerebrovascular accidents (strokes). The old diagnosis code for strokes - 436 (Acute, but ill-defined, cerebrovascular disease) - now specifically excludes CVAs and points coders to the 434 code series for various CVA diagnoses (see Eli's OASIS Alert, Vol. 5, No. 10, p. 94).
 
This change only added to the confusion about whether home care coders could use acute CVA codes, or were required by coding guidelines to use late effect CVA codes (438 series), once the patient leaves the acute setting.
 
In the original OASIS instructions, the Centers for Medicare & Medicaid Services assigned code 436 a case mix weight that adds points to the episode payment. CMS told agencies they could use acute CVA codes as long as the patient is making progress with rehabilitation, even in the home setting.
 
Issue: Home health agencies changed coding practices in October 2003 to comply with the requirements of the Health Insurance Portability and Accountability Act, which requires them to adhere to ICD-9 coding guidelines. One of those guidelines is that acute CVA codes are reserved for initial treatment in the hospital, according to the American Health Information Management Association. Ever since then, agencies have been wondering what to do about CVAs.
 
Bottom line: CMS will update its guidance to reflect the new codes and will continue to allow agencies to use acute CVA codes in the home setting, a CMS official now says.

In a Nov. 15 written answer to a request for clarification of CVA coding from Josephine Sienkiewicz of the Home Care Association of New Jersey, CMS says even with the change from ICD-9 code 436 to 434.91 or related codes, the exception CMS granted HHAs, allowing them to use acute CVA codes, still holds. The 434 codes are already included as case mix codes, the official explains.
 
"Because the grouper does not give points to 438 we will continue to issue the guidance on CVA and Strokes that was originally published in the 'Diagnosis Coding for Medicare Home Health Under PPS' as a business decision," a CMS official says.
 
CMS plans to update the guidance "to reflect the appropriate utilization of code categories 430 to 435 instead of code 436," the official continues.
 
Sienkiewicz' request for clarification contained sections excerpted from the guidance and clearly showed the need for CMS to provide further information, she tells Eli. The agency responded very quickly, she adds.