OASIS Alert

Co-morbidities are vital to accurate reimbursement.

Your biggest OASIS challenge for 2008 may be coding sequencing. Blow that, and you won't get the case mix points you deserve, even if all your codes are correct.

New payment question M0246 has six slots, and "they are all potential case mix slots," says Las Vegas-based home health clinical and coding consultant Sharon Molinari. Many people are still confused by M0245, and M0246 is six times more confusing, Molinari says.

Why? If you place a V code in the primary or any of the secondary diagnosis positions in M0230 and M0240 -- and the V code replaces a case mix diagnosis -- you have an opportunity to gain case mix points for the episode.

But knowing when to report a V code and where to list it can be confusing. To help make your decision, try asking how important the V code is, says Lisa Selman-Holman, consultant and principal of Selman-Holman & Associates in Denton, TX.

What to do: If the V code is important and it replaces a numerical case mix code, put it in one of the top six OASIS diagnosis slots, she says. If it's not as important, then code it at the bottom of the list.

Key to knowing when a V code is important is understanding how to determine the focus of care. Look to the OASIS assessment and the information you have from the hospital or physician. Together with the plan of care, these determine the focus of care and the secondary diagnoses that may impact the care, says Molinari.

Example: Your patient was admitted for home care following an open reduction with internal fixation (ORIF) for a hip fracture after falling at home. He also has cystitis due to a Foley catheter that is still in place for urinary retention. Nursing is ordered for post-op and genitourinary assessment, teaching, and staple removal. Physical therapy will provide gait training.

Where is the focus? In this multi-disciplinary case, the primary focus of care for both nursing and therapy is aftercare for the healing traumatic hip fracture, says Molinari. So V54.13 (Aftercare for healing traumatic fracture of hip) is the principal diagnosis you would list in M0230. Next, you would code 781.2 (Abnormality of gait) in M0240b. Follow this with 996.64 (Infection due to indwelling urinary catheter), which in-structs you to use an additional code to identify the infection, 595.9 (Cystitis, unspecified).

Also, list 788.20 (Retention of urine, unspecified) and V58.32 (Encounter for re-moval of staples), Molinari says. In addition, you may add the optional E code for the fall at home (E849.0), she says.

Mistake: Do not code V53.6 (Fitting and adjustment of urinary catheter) because the patient has the urinary infection.

Because in this scenario the V code listed in M0230 replaces a case mix diagnosis -- 820.8 (Fracture of neck of femur; unspecified part of neck of femur, closed) -- place 820.8 in M0246 Column 3 for the case mix points, Molinari says. Leave M0246 Column 4 blank because this column is used only in mandatory multiple coding situations, such as manifestations, she says.

You'll generally sequence "aftercare following surgery" codes such as V58.4x (Other aftercare following surgery) or V58.7x (Aftercare following surgery to specified body systems, not elsewhere classified) as primary if the patient had surgery, there are no complications and aftercare is the focus of care, says Selman-Holman.

Don't overlook: But ask first if there is a complication, because an acute condition trumps a V code, says Selman-Holman. Also, even though you are also providing aftercare, consider whether another diagnosis is really the reason for home care.

Example: Your patient had gall bladder surgery, but while in the hospital her hypertension exacerbated and she contracted an upper respiratory infection causing her chronic bronchitis to exacerbate. While you may be providing aftercare following surgery, the aftercare is not the focus of care for this patient, says Sel-man-Holman. Instead you would list:

• M0230a: 401.9 (Essential hypertension, unspecified);

• M0240b: 491.22 (Obstructive chronic bronchitis; with acute bronchitis);

• M0240c: V58.75 (Aftercare following surgery of the teeth, oral cavity, and digestive system, NEC); and

• M0246c(3): 575.10 (Cholecystitis, NOS).

Most V codes are "reason-for-encoun-ter" codes and do not give a clue to the underlying condition, Selman-Holman says. It's best to list the condition codes prior to reporting such V codes as V58.31 (Encounter for change or removal of surgical wound dressing) or V58.83 (Encounter for therapeutic drug monitoring), she says.

Co-morbidities play a big role under the revised PPS, Molinari says. If the patient has diabetes or hypertension he might be stable, but you still need to report these conditions because they may affect his care, she says. For example, diabetes could slow the healing. Blindness, congestive heart failure, and coronary artery disease -- co-morbidities that should also always be coded -- are now case mix diagnoses that need to be in the top six positions in order to get case mix points, Molinari says.