OASIS Alert

Don't base principal diagnosis on number of visits by discipline.

Accurately reporting your patient's diagnoses is essential in representing the care you provide. Make sure you aren't missing out on case mix or risk adjustment points by following these tips for completing M1020 and M1022 accurately.

OASIS item M1020 asks you to list your patient's primary diagnosis while M1022 offers five slots for reporting co-morbidities.

You'll list each diagnosis for which your patient is receiving home care in column 1 of the M1020/M1022/ M1024 grid and then enter the corresponding ICD-9 code in column 2. The ICD-9 codes you list should be at the level of highest specificity, and include all required digits.

Important: If the diagnosis codes you list in your responses to these items fall into the diabetes, skin 1, or neuro 1 case mix categories, you could earn additional points for the care you provide these patients. See the Clip and Save on page 99 for a breakdown.

Note: Watch for an article about completing M1024 in next month's OASIS Alert.

As the assessing clinician, you must determine the diagnoses and conditions you'll report in M1020/M1022. You can collect the information you need to do so from the patient, family and/or physician, says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, HCSO, director of coding with Foundation Management Services in Denton, Texas. And you can work with acoding specialist to establish correct sequencing and help interpret the official coding guidelines.

The diagnoses you list in M1020/M1022 must be:

• Compliant with ICD-9 coding guidelines
• Unresolved
• Relevant medical diagnoses; and
• Supported by the patient's medical record documentation

When your patient has multiple diagnoses, you'll need to sort out which one to list in M1020 as the principal reason for home care. The principal diagnosis is the  diagnosis most related to the current plan of treatment, 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. This diagnosis may or may not be related to your patient's most recent hospital stay, but must relate to the services your agency provides.

Mistake: Don't assume that you can select the principal diagnosis by looking at which discipline is providing the most visits and listing the condition they will be focusing on. "Rarely is the number of visits by discipline the determining factor in selecting the principal diagnosis," Selman-Holman says.

Instead, if you're caring for more than one diagnosis during this episode, list the diagnosis that represents the most acute condition and requires the most intensive skilled services in M1020, Selman-Holman says.

And remember that the focus of care may change with each episode, Selman-Holman says. Don't assume the principal diagnosis you reported when your agency began providing care is still the primary reason for home care. Review the diagnosis codes you list in M1020 and M1022 at each OASIS assessment timepoint.

Tip: If two or more diagnoses both meet the definition of primary, you may choose which one to list in M1020. Your primary diagnosis should be reflected in the Plan ofCare and in the subsequent clinical notes.

2. List the Secondary Diagnosis Codes

When it comes to diagnosis codes, "secondary" doesn't mean second. Instead, this term indicates that the patient has additional co-morbidities. With OASIS-C, Medicare has renamed these diagnoses "other."

So what are secondary diagnoses? All conditions that coexisted at the time the plan of care was established, or which developed subsequently, or affect the treatment of care, says Selman-Holman.

Secondary diagnoses include conditions actively addressed in the plan of care and any co-morbidity affecting the patient's responsiveness to treatment and rehabilitative prognosis, even if the condition is not the focus of any home health treatment itself, Selman-Holman says.

Mistake: Don't list diagnosis codes for conditions of mere historical significance and without impact on the patient progress or outcomes in M1022, Selman-Holman says. However, you may use history codes such as V10 (Personalhistory of malignant neoplasm) if the historical condition has an impact on current care or influences treatment.

The first step in sequencing your diagnosis codes is to decide which diagnosis is principal. List this diagnosis, the chief reason for home care, in M1020. Remember this won't necessarily be the primary diagnosis that was listed during the patient's inpatient stay.

Next, consider which other diagnoses need active intervention. You'll pull the diagnoses you want to list in M1022 from this list.

Which of these other diagnoses will impact the healing or recovery of the primary diagnosis the most? You'll want to try to fit these co-morbidities in an M1022 slot.

What other diagnoses will impact the care even if interventions are not needed? Include these diagnoses in M1022 as space permits. Then, list any remaining diagnoses on the plan of care.

Once you have your list of diagnosis codes selected and organized, you'll need to assign symptom control ratings. See the sidebar below for help with this next step.

Those diagnoses that will impact care, even though the symptoms are controlled, will still need interventions, Selman-Holman says. For example, you're likely to need to assess for exacerbations, teach the patient or caregiverwhat symptoms to report, and assess for continued compliance with medications or other treatments that may be controlling the particular conditions, she says.