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ICD-9 Coding:

Keep Diagnoses in Order to Maximize Nonroutine Supply Points

Published on Wed Mar 02, 2011

Here are the seven categories you should track to get the NRS payment you deserve.

Nonroutine Medical Supplies can earn valuable case mix points, which means more reimbursement for your agency. But how these points are calculated isn't always straightforward. Get the background you need to make sure you are securing the payment you are due.

Know These NRS Reimbursement Building Blocks

Your agency is eligible for Nonroutine Supply (NRS) reimbursement based on OASIS responses, even if you don't actually provide the supplies specific to the diagnosis, says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, director of coding with Foundation Management Services in Denton, Texas.

How it works: NRS points are calculated based on OASIS responses and coding, not on the type of or quantity of supplies provided, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. If supplies are not provided, the HIPPS code you report ends in a number and the supply reimbursement is not paid. If the claim indicates that NRS were provided (the HIPPS code ends in a letter), then the NRS reimbursement is received. Keep in mind that the claim needs to include the revenue code for the NRS and the charges only without specificity as to HCPCS codes, quantities and types of NRS, she says.

NRS reimbursement is calculated using:

  • OASIS combinations
  • Numerical case mix diagnoses
  • Selected V codes
  • Seven case mix categories

Mind Your Sequencing

Sequencing impacts the number of NRS points you'll earn for reporting diagnoses in the seven selected case mix categories. When a diagnosis from one of these categories is the focus of your care and reported as primary in M1020 you're eligible for more points than when the same diagnosis is reported in M1022. The difference breaks down as follows, Twombly reports:

Cancer diagnoses
  • 172.x (Malignant melanoma of skin)
  • 173.x (Other malignant neoplasm of skin)

Listed as primary: 15 NRS points

Listed as secondary: 4 NRS points

Diabetes diagnoses
  • 250.8x (Diabetes with other specified manifestations) paired with manifestation 707.1x (Ulcer of lower limbs except pressure ulcer).
  • 249.8x (Secondary diabetes mellitus with other specified manifestations) paired with manifestation 707.1x (Ulcer of lower limbs except pressure ulcer).

Listed as primary: 20 NRS points

Listed as secondary: 0 NRS points for diabetic ulcer, however the ulcer code gains 13 points as a Skin 2 code.

Skin 1 diagnoses
  • Trauma (open) wounds/burns
  • Complicated surgical wounds:

Dehiscence

Infection

Foreign body accidentally left during procedure

Non-healing

Persistent fistula

Listed as primary: 19-23 NRS points

Listed as secondary: 8-15 NRS points

Ortho 1 diagnoses
  • 897 (Traumatic amputation of leg[s] [complete] [partial])

Listed as primary: 19 NRS points

Listed as secondary: 8 NRS points

Skin II diagnoses
  • Abscess
  • Cellulitis
  • Gangrene
  • Ulcers

Listed as primary: 11-16 NRS points

Listed as secondary: 7-13 NRS points

Tracheostomy
  • V55.0 (Attention to tracheostomy)

Note: You must be doing something to or about the ostomy to earn NRS points.

Listed as primary: 23 NRS points

Listed as secondary: 23 NRS points

Note: You will earn 0 NRS points if the ostomy is infected because you can't report a V code when there is a complication

Urostomy/Cystostomy
  • V55.5 (Attention to cystostomy)
  • V55.6 (Attention to other artificial opening of urinary tract)

Note: You must be doing something to or about the ostomy to use the V55 code to earn NRS points.

Cystostomy listed as Primary or Secondary: 16 NRS points

Urostomy listed as Primary or Secondary: 24 points

Note: You will earn 0 NRS points if the ostomy is infected because you can't report a V code when there is a complication

See Why Sequencing Matters

The NRS points you receive will vary, depending on where you list a diagnosis from one of the seven eligible categories. In some cases, if the diagnosis isn't the main focus of your care, you won't be eligible for NRS points.

Coding example: Your patient was admitted for chronic obstructive pulmonary disease (COPD) exacerbation, but also has type II diabetes mellitus with a diabetic ulceron the right great toe. The diabetes is managed with an oral hypoglycemic and the patient requires continuous oxygen. Code for this patient as follows, says Twombly:

  • M1020a: 491.21 (Obstructive chronic bronchitis; with [acute] exacerbation);
  • M1022b: 250.80 (Diabetes with other specified manifestations; type II or unspecified type, not stated as uncontrolled);
  • M1022c: 707.15 (Ulcer of other part of foot); and
  • M1022d: V46.2 (Dependence on supplemental oxygen).

Your patient's COPD is the main reason you are going to the home, so this is your primary diagnosis listed in M1020, Twombly says.

You'll list the underlying condition/manifestation code pair 250.80 and 707.15 next, but you won't gain any NRS points for this diabetic ulcer combination because the codes are listed as secondary diagnoses. However, you will be eligible for 13 NRS points for reporting a nonpressure, non-stasis ulcer with 707.15, Twombly says.

Finally, list V46.2 to indicate to your intermediary just how decompensated your patient is, Twombly says.

On the other hand: If your focus of care were the patient's diabetic ulcer, you could list 250.80 in M1020a as the primary diagnosis code with 707.15 following in M1022b. This sequencing would earn you an additional 20 NRS points.

Key: "NRS points add to the bottom line," says Jan McLain, RN, BS, LNC, HCS-D, COS-C, with Adventist Health System Home Care in Port Charlotte, Fla.

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