OASIS Alert

It's safe to list HTN as primary, just make certain your documentation is supportive.

Back in July 2010, the Centers for Medicare & Medicaid Services proposed eliminating two hypertension codes from the case mix diagnoses list. But the final rule, published in the Nov. 17 Federal Register, brought a reprieve.

Good coding news: "We are ... withdrawing our proposal to eliminate ICD9-CM diagnosis codes 401.1, Benign Essential Hypertension, and 401.9, Unspecified Essential Hypertension, from the HH PPS case-mix model's hypertension group, pending the results of a more comprehensive analysis of the resource use of patients with these conditions," CMS says in the final rule. The proposed elimination had drawn strident comments from the industry. The agency seemed especially impressed with a commenter's point that while agencies have to wait for hypertension documentation from the physician, they often have to code the patient as 401.9.

Remember: Coding guidelines require you to have physician documentation of whether HTN is malignant or benign in order to code these specifics. If the physician doesn't specify, then you must code for the HTN as unspecified with fourth digit "9."

Financial consultant Mark Sharp with BKD in Springfield, Mo. applauds this change, noting "the elimination would have been duplicative of some of the case mix creep reduction."

Restoring the hypertension codes in the case mix calculation probably staved off a 1.8 percent reimbursement reduction, estimates the National Association for Home Care & Hospice.

While agencies might not be happy with everything in the rule, "it was very good to see CMS back off on some of the proposed provisions," such as the hypertension change, Sharp tells Eli. "It appears that CMS listened to the comments on some of the matters and made positive revisions from the proposed rule."

The fact that CMS heeded input from providers and industry experts "magnifies the importance of being involved in advocacy as an industry," Sharp stresses.

Watch out: CMS may have backed off of removing the hypertension codes from the case-mix methodology this year, says Chicago-based regulatory consultant Rebecca Friedman Zuber. "But they'll do it next year," she predicts.

CMS' criticism of home care's alleged overuse of the hypertension codes, along with medical edits from several regional home health intermediaries (RHHI), had some coders concerned about when it's appropriate to list an HTN diagnosis code.

Before you list a HTN -- or any other co-morbidity -- as a secondary diagnosis, make sure it fits one of two qualifications for inclusion:

1. The diagnosis should be addressed in the plan of care; or

2. You should have detailed documentation about how the diagnosis will impact the patient's care or changethe way you're going to provide care.

Caution: Case mix diagnosis codes, like the HTN codes, attract auditors' attention because they are an easy place to find potential over-payments. To safeguard your claims, make sure your documentation backs up the codes you report.

Can you list a chronic condition, such as HTN, as the principal diagnosis? Yes you can, says Lisa Selman-Holman, JD, BSN, RN, HCSD, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

Example: Suppose your patient has severe HTN, Selman-Holman suggests. Her primary physician made conservative changes during the first two certification periods, but those changes did not get the HTN under control. She started seeing a cardiologist, who made several medication changes, and the HTN is finally starting to be controlled. Because her blood pressure isn't entirely stable, she still requires teaching and monitoring. This patient also has a couple of chronic conditions that are controlled, but none of them involve teaching and monitoring.

"In this scenario, you would absolutely list HTN first," Selman-Holman says. Why? "You are using your nursing skills to teach and monitor," she says.

Medical edits such as those which are currently looking at HTN coding don't just examine the code choice, Selman-Holman says. The medical reviewers are looking to see whether the condition requires skilled care. They ask whether the condition has the potential for fluctuation and thus qualifies for skilled observation and assessment, she says. Simple assessment, such as taking the blood pressure, is not considered skilled care, she says. The nurse must be assessing and acting appropriately based on that assessment for the care to be considered skilled.

Bottom line: Your HTN coding may get caught in an edit, but your thorough documentation will prevail, Selman-Holman says.