GUIDE TO HOME HEALTH DIAGNOSIS CODES

Transcription

1 GUIDE TO HOME HEALTH DIAGNOSIS CODES Proper selection of diagnoses codes for the Medicare OASIS Assessment The process of selecting correct diagnosis codes for the OASIS Start of Care, Re-Certification or Resumption of Care is very straightforward and uncomplicated. Include only problems (diagnoses) for which there is a change in medications or skilled treatments. If a patient is to receive home health services paid for by Medicare, the services must be ordered by a licensed physician the patient must have an unstable condition there are new or changed treatments/medications for the unstable condition the patient must be homebound. The diagnoses codes to be documented in the OASIS assessment under M1022/4 are reflective of the unstable condition(s) ONLY. If a condition has no medical or skilled treatment changes (and ordered by the physician) the diagnosis should NOT be included in the list. A condition requiring a new or changed medication, therapy and/or a new/changed skilled nursing treatment is appropriate for inclusion on M1022/4. It can be tempting It can be tempting to include diagnoses that are stable - especially stable case-mix diagnoses - because they yield the HHA potentially more reimbursement. This practice of using stable casemix diagnoses is called up-coding and is an unacceptable method of coding. For example For example, a patient is admitted to an HHA with a history of CHF, hypertension, Diabetes Mellitus, chronic pain, exacerbation in psoriasis. The only change to the medical careplan is a new medication for psoriasis. Although the patient has multiple health problems, there are no changes to the treatments except the treatment for psoriasis. Since that is the case, only psoriasis should be listed on the diagnosis list. Conditions requiring no change to the careplan are considered stable and should not be on the diagnosis list.

2 For supporting documentation please refer to CMS s guide to home health diagnosis coding go Instruments/HomeHealthQualityInits/downloads/HHQIAttachmentD.pdf How to Use Etiology and Manifestation Diagnoses Correctly on the OASIS Assessment In certain cases, ICD-9-C M guidelines require more than one code to report a condition. The use of two codes in is called mandatory multiple coding, dual classification, dual coding, or mandatory dual coding. One specific example of such mandatory dual coding is termed etiology/manifestation conventions and involves the reporting of both a disease (the cause or underlying problem) and one of its manifestations (the effect or another condition caused by the problem). Etiology versus Manifestation The etiology cause code is the underlying disease and must be listed first, before the code for a related manifestation. When a diagnosis is under consideration as an etiology diagnosis, the HHA is expected to ensure that a valid manifestation code is sequenced immediately following the assignment of the etiology code. The manifestation diagnosis is the relevant condition caused by the underlying disease and is never assigned as the patient s primary diagnosis. A good example Arthropathy cannot be coded by itself. Arthopathy is a manifestation code and always caused by another underlying problem. One cause of Arthopathy is Diabetes Hence, if you are using Arthopathy on your M1022/4 list, you must list it UNDER the etiology code will be listed ABOVE on the list. Dual coding rules apply to M1010, M1016 & M1022/4 Dual coding applies to the three diagnosis sections on the OASIS assessment: M1010, M1016 & M1022/4. Refer to CMS Guidelines For supporting documentation please refer to CMS s guide to home health diagnosis coding go Instruments/HomeHealthQualityInits/downloads/HHQIAttachmentD.pdf

3 How to Use V-Code Diagnoses Correctly on the OASIS Assessment The use of a V-codes on OASIS is considered an assignment of last resort. A V-code refers to a treatment protocol for a known disease, such as dialysis for kidney disease requiring, physical therapy for a fractured hip or medication monitoring for Coumadin or Theophyline. The underlying reason for the v-code procedure code must accompany a V code to support the treatment being performed. V codes indicate a reason for an encounter. V codes are used to deal with occasions when circumstances other than a disease or injury are recorded as diagnoses or problem. An example An 85-year-old independent female sustained a left hip fracture resulting in a hospital stay for an open reduction with internal fixation. Following her discharge from the hospital, she is admitted to a skilled nursing facility (SNF) where she is scheduled to be discharged from the SNF to her home where she will receive skilled therapy services. Her physician orders non-weight bearing activity to her left lower extremity with supervised pivot transfers and contact guard assist in and out of bed. Skilled Nursing: The HHA did not receive an order from the patient s physician to provide skilled nursing services. The initial assessment visit by the HHA did NOT identify skilled nursing needs. Therapy Need: The physician ordered physical therapy (PT) for gait evaluation/training and strengthening exercises three times per week for four weeks. The patient s ambulation is limited due to the non-weight bearing status of her left leg. This is her first episode of home health care. Twelve therapy visits are ordered by her physician for this episode of care. M1022: V57.1, Other physical therapy. M1024: 781.2, Abnormality of gait V57.1 is selected as the patient s primary diagnosis and assigned to M1022. The rehabilitation code V57.1, Other physical therapy, qualifies as the patient s M1022 primary diagnosis because the focus of the patient s current home health plan of care is to provide rehabilitation through therapeutic physical therapy. Coding guidelines for V57 instructs the HHA to use an additional code to identify the patient s underlying condition on M1024 Code 781.2, Abnormality of gait, is identified as the patient s underlying condition on M1024.

4 Why are we switching to ICD-10-CM? There have been delays On January 16, 2009, the Department of Health and Human Services (HHS) published a regulation requiring the replacement of ICD-9 with ICD-10 as of October 1, In February 2012, HHS announced it was considering delaying the compliance date again due to feedback from the industry, including from the AMA. On September 5, 2012 HHS published a regulation that pushed back the compliance date one year to October 1, 2014, in part due to concerns about meeting the 2013 deadline given several other competing deadlines providers must meet. All assessments on or after October 1, 2014 must use the ICD-10 codes. Assessments and invoices/claims submitted with ICD-9 codes will be rejected. The regulation names ICD-10- CM for reporting diagnoses in all clinical situations. CPT and HCPCS will continue to be the code sets for reporting procedures in outpatient and office settings. Because ICD-10 is replacing ICD-9 as a HIPAA-named code set, covered entities, defined in HIPAA as health care providers, including home health agencies are required to comply with the regulation. Although HIPAA requirements specifically apply to the HIPAA-named electronic transactions, payers (Medicare, Medicaid etc) are expected to require ICD-10 codes on transactions submitted using other methods, such as on paper (e.g., 1500 claim form), through a dedicated fax machine, or via the phone. CMS is the agency within HHS that is responsible for oversight of the implementation and compliance with the regulation. Additional resources are available on the CMS website: ICD-9 is Outdated While there are many providers who believe the implementation of ICD-10 is unnecessary and burdensome, there are other physicians and industry stakeholders who believe that the ICD-9 code sets have become too outdated and are no longer workable for treatment, reporting, and payment processes today. ICD-9 has been used widely in the U.S. since The World Health Organization (WHO) endorsed ICD-10 in 1990 and many countries have adopted versions of it. he age of ICD-9 means that it does not accurately reflect all advances in medical technology and knowledge. The ICD-9 diagnosis codes are divided into chapters based on body systems. We ve Run out of Codes in ICD-9 During the years of maintaining and expanding the codes within Chapters, the more complex body systems have run out of codes. The lack of codes within the proper chapter has resulted in

5 new codes being assigned in chapters of other body systems. For example, new cardiac disease codes may be assigned to the chapter for diseases of the eye. The rearranging of codes makes finding the correct code more complicated. ICD-9 Doesn t Meet Medical Advances Another driver for replacing ICD-9 is the increased specificity of ICD-10. It is believed that the more specific data will provide better information for identifying diagnosis trends, public health needs, epidemic outbreaks, and bioterrorism events. The more precise codes also have the potential benefit for fewer rejected claims, improved benchmarking data,improved quality and care management, and improved public health reporting. MyHomecareBiz Virtual Director of Nursing Services Performs Diagnosis Coding Services Virtual Director of Nursing services include utilization review, OASIS documentation and chart review, diagnosis coding, physician order tracking and progress note review. Our team of experienced home health RNs and coders can be your 'extra set of hands' working behind the scenes to make sure your assessments are coded properly and your charts pass the scrutiny of a Medicare surveyor or RAC audit team. Please call (888) x3 for more information.