In this week’s Question of the Week, Jennifer Osburn answers a question related to Coding Conventions for Home Health Agencies
Q: Can we have clarification on coding conventions for home health agencies? We understand that we must have documentation from the physician to support the codes that appear on the 485/plan of care. Does this documentation have to be signed by the physician? Does the physician signing the 485/plan of care count? We are having more and more difficulty with our internal coders and contracted coding companies refusing to code the 485/plan of care because they do not have signed documentation from the physician. This is negatively impacting our authorization and billing process as some of our payers require the completed OASIS and 485/plan of care when requesting authorization for the services provided.
A: The physician or allowed practitioner’s orders and medical records are the basis on which diagnoses are assigned to medical records, including home health records, under HIPAA, ICD-10 Coding Conventions and Guidelines, and OASIS Guidelines. The documentation would need to be signed by the provider (no later than prior to the claim being submitted for Medicare) to support legally that the diagnosis exists. A patient’s statement that they have a disease is not adequate for assigning a diagnosis, nor is the presence of medications that may be used for certain diagnoses treatments. If there is a question regarding whether the patient has a certain diagnosis, the physician or practitioner would need to be contacted and query occur. Documentation of this conversation and results of the conversation may be used to support the assigned diagnosis(es). However, simply listing diagnoses on the plan of care without provider documentation and/or documented physician/provider query is not acceptable practice. We recommend that you ask the referral source for all H&P, DC summaries, and Consultation notes pertinent to the home health referral and plan of treatment so that adequate information is available for processing the referral, assessing the patient and completing OASIS and plan of care and for supporting authorization requests. In addition, when coding a new Start of Care in home health, the primary diagnosis must have been treated during the required Face-to-Face (F2F) encounter. Therefore, the coders are going to need the actual F2F note prior to coding the chart.
According to the OASIS Guidance Manual regarding diagnoses listed:
“The assessing clinician must determine the primary and other home health diagnoses based on the assessment findings, information in the medical record including but not limited to physician/allowed practitioner orders, medication list and referral information, and input from the physician/allowed practitioner.”
“Adherence to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines for Coding and Reporting when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). It is expected that each agency will ensure that diagnoses and ICD-10-CM codes reported in OASIS meet these guidelines.”
Additionally, 2026 Official Guidelines and Conventions for ICD-10-CM state:
Code assignment and Clinical Criteria:
“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider.”
Documentation by Clinicians Other than the Patient’s Provider:
“Code assignment is based on the documentation by the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). There are a few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). In this context, “clinicians” other than the patient’s provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient’s official medical record. These exceptions include codes for:
- Body Mass Index (BMI)
- Depth of non-pressure chronic ulcers
- Pressure ulcer stage
- Coma scale
- NIH stroke scale (NIHSS)
- Social determinants of health (SDOH) classified to Chapter 21
- Laterality
- Blood alcohol level
- Underimmunization status
- Firearm injury intent
This information is typically, or may be, documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, pressure ulcer, or a condition classifiable to category F10, Alcohol related disorders) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s provider should be queried for clarification. The BMI, coma scale, NIHSS, blood alcohol level codes, codes for social determinants of health and underimmunization status should only be reported as secondary diagnoses.”
Finally, the Surveyor’s Guidance Manual states, regarding the plan of care:
“In general, pertinent diagnoses include, but are not limited to, the chief reason the patient is receiving home care and the diagnosis most related to the current home health plan of care. Additionally, comorbid conditions that exist at the time of the assessment, that are actively addressed in the patient’s Plan of Care, or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis should be considered and documented.”
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