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Diagnosis Coding:

UNDERSTAND OASIS/CODING FUSION TO RECOUP YOUR DESERVED PAY

Published on Thu Feb 12, 2009

For accurate results, don't stop with the first pass.

If you accept poor documentation without questioning it, you might as well throw money out the window.

Under the current home health prospective payment system, the OASIS assessment interacts with diagnosis coding choices in a complex way. You no longer can assume a specific diagnosis provides a specific number of case mix points, said Trish Twombly, directorof coding with Foundation Management Services in Denton, Texas during her recent Eli-sponsored audioconference, Coding and PPS: Lessons Learned Through 2008 Changes.

Use the following scenarios to see if you can ace the intricacies of PPS assessment and coding or if you need a refresher course.

OASIS Answers Matter

Scenario: Your patient is being admitted for an exacerbation of multiple sclerosis. Physical therapy will care for the patient's ataxia, and nursing will provide observation and assessment. The start of care (SOC) OASIS includes the following answers:

• M0670 (Bathing): 1

• M0680 (Toileting): 0

• M0690 (Transferring): 1

• M0700 (Ambulation): 2

For this patient, you would report the following codes, Twombly said:

• M0230: 340 (Multiple sclerosis); and

• M0240: 781.3 (Lack of coordination).

Old way: In 2007 this coding would have earned your agency 20 case mix points for the neuro diagnosis 340.

New way: Under the revised PPS, case mix points for multiple sclerosis depend on answers to the OASIS questions, Twombly explained. You would earn no case mix points for this patient unless the OASIS answers for bathing, toileting, transferring, and ambulation are higher than the scenario reports.

Strategy: Don't score the OASIS with case mix points in mind, Twombly reminded clinicians. But do remember a "thorough and complete OASIS assessment is important to coding and reimbursement." The functional OASIS M0 items are some of the most difficult for clinicians to answer correctly, and you must always keep safety in mind, she said. Review the functional OASIS M0 item tips, strategies, and questions and answers the Centers for Medicare & Medicaid provides.

There's an enormous difference between "ShowMe" and "TellMe" approaches to scoring the functional domain of the OASIS, says Jun Mapili, PT, MAEd, with Global Home Care in Troy, Mich. Interviewing the patient while completing the assessment is helpful, but relying solely on an interview rather than asking the patient to demonstrate activities, such as upper body dressing, can work against your agency, he says.

Sequencing Choices Can Cost You

Scenario: Your patient was admitted to home care due to an abdominal surgical wound that has dehisced. She also has an infected second degree burn to the hand from scalding water. Both wounds will require equal attention from the nurse.

Options; You have two options for sequencing this scenario, Twombly said. According to the ICD-9-CM Official Coding Guidelines, when you have two conditions that both meet the rules for a primary diagnosis, you can choose which one to list as primary.

Option A is to list:

• M0230a: 944.20 (Burn of wrists and hands; blisters, epidermal loss [second degree];hand, unspecified site);

• M0240b: 998.32 (Disruption of internal operation [surgical] wound); and

• M0240c: E924.0 (Accident caused by hot substance or object, caustic or corrosive material, and steam; hot liquids and vapors,including steam).

Option B is to list:

• M0230a: 998.32

• M0240b: 944.20

• M0240c: E924.0

Strategy: The order in which you list a patient's diagnosis codes can make all the difference in how your agency is paid. List diagnoses in the order that best reflects the seriousness of the patient's condition and justifies the disciplines and services you provide, Mapili says.

In this scenario, both diagnoses are from the Skin 1 category, which will receive 10 points for low therapy cases and 20 points for high therapy. So does your sequencing still matter? The answer is yes, Twombly said.

In this scenario, option A will earn your agency 19 nonroutine supply points, while option B will earn 23 nonroutine supply points.

Dig Deeper Into Documentation

Scenario: Your patient had a stroke resulting in hemiplegia on her dominant side. She also has hypertension and arthritis. Your agency will be providing skilled nursing,speech therapy, and physical therapy,but you can't find a reason for the speech therapy in the documentation. You also notice that she is receiving medication used to treat GERD, but there is no documented diagnosis for this condition.

With the existing documentation you should report these codes :

• M0230a: 438.21 (Late effects of cerebrovascular disease; hemiplegia affecting dominant side);

• M0240b: 401.9 (Essential hypertension,unspecified); and

• M0240c: 716.99 (Arthropathy, unspecified;multiple sites).

Result: You would gain zero case mix points for the stroke and three points for the hypertension, for a total of three points in an early episode with less than 14 therapy visits. An extra point is available for the stroke with a dressing disability, and another point is available if ambulation (M0700) is scored with at least a 3.

Strategy: Taking the extra step to consult with the clinician who completed the OASIS assessment can pay off. Say a call to the nurse in the scenario above resulted in new documentation that included a GERD diagnosis and a reason for speech therapy -- dysphagia. With this new information in the plan of care, you could now report the following codes,Twombly said:

• M0230a: 438.21 (Late effects of cerebrovascular disease; hemiplegia affecting dominant side);

• M0240b: 438.82 (Other late effects of cerebrovascular disease; dysphagia);

• M0240c: 787.20 (Dysphagia, unspecified);

• M0240d: 401.9 (Essential hypertension,unspecified);

• M0240e: 530.81 (Esophageal reflux);and

• M0240f: 716.99 (Arthropathy, unspecified;multiple sites).

Payoff: With the new documentation,your agency would earn an additional two points for the dysphagia, plus another two points for the GERD.

You can only list diagnosis codes for the conditions documented in the medical record. But you can do detective work to sleuth out diagnoses that may have slipped through the cracks.

Personalize Therapy Visits To Patient Needs

Scenario: Suppose the same patient in the scenario above had 12 therapy visits ordered in M0826. However, giving closer scrutiny to her clinical and functional data it appears she is being underserved and would benefit from more than 14 therapy visits.

Upside: The increased therapy visits would increase the case mix points your agency would receive for her care, Twombly said. For the stroke, the case mix would increase from zero to a possible eight points,for the dysphagia from two to six points, for the hypertension from three to seven points,and for the GERD from two to six points, bringing the total case mix points for this patient from eight to twenty-seven.

Bonus: Paying close attention to the acuity of each patient and appropriate therapy needs can improve outcomes and reimbursement.

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