The updated ICD-10 code set will take effect on October 1, 2026, bringing 184 new diagnosis codes along with revisions to numerous existing codes. These changes affect several diagnosis categories, making it important for coding staff to begin reviewing the updates now so they understand how the revisions may impact coding accuracy and documentation requirements.
As October approaches, keep in mind that the ICD-10 update may create some billing challenges. You may have patients whose 60-day episode or benefit period begins before October 1 using a diagnosis code from the current code set, but that code could be revised, replaced, or deleted when the new ICD-10 updates take effect. When billing occurs after October 1, those claims may need to be updated to reflect the new code set. Be sure your billing team is aware of these potential issues and prepared to make any necessary corrections.
Additionally, it’s important to understand the role coding plays in both home health and hospice. For home health agencies, it’s important that coders have access to the face-to-face encounter documentation when coding a new Start of Care. The documentation should clearly support the patient’s primary reason for home health services. CMS has clarified that the ICD-10 diagnosis code documented in the face-to-face encounter does not have to be an exact numeric match to the code used on the home health plan of care. However, the clinical condition driving the need for home health must be addressed in the encounter documentation. For example, if congestive heart failure is the patient’s primary focus of care, the face-to-face note should include documentation showing that heart failure was evaluated, treated, or discussed during that visit.
It’s also important to ensure that every active diagnosis is coded to the highest level of specificity supported by the documentation. Accurate, specific coding plays an important role in PDGM reimbursement because secondary diagnoses are evaluated when determining whether a patient qualifies for a low or high comorbidity adjustment. Missing specificity or incomplete coding can affect both payment accuracy and the overall clinical picture reflected in the medical record.
For hospice agencies, accurate diagnosis coding is just as important. Be sure the patient’s terminal diagnosis is coded correctly, along with any additional conditions that contribute to or impact the patient’s terminal prognosis. One area that often causes confusion is understanding which diagnoses should be included. Many people recognize that conditions related to the terminal illness must be coded, but it is equally important to evaluate all diagnoses that influence the patient’s overall prognosis and plan of care.
The terminal diagnosis represents a disease process by which the patient is primarily dying. However, it is not the only diagnosis that may need to be reported. Any additional condition that contributes to or affects the patient’s overall terminal prognosis should also be evaluated for coding, even if it is not directly part of the terminal diagnosis itself.
We also need to be especially careful in this area because Medicare Part B and Medicare Part D services provided to hospice patients during an active hospice benefit period continue to receive significant scrutiny. It is essential to accurately code every diagnosis that contributes to the patient’s overall terminal prognosis. Doing so helps ensure there is a clear understanding of which conditions are related to the terminal illness and that services associated with those diagnoses are appropriately covered by the hospice, helping reduce billing and compliance concerns.
Healthcare Provider Solutions provides professional coding services for both home health and hospice agencies nationwide. Our experienced coding team supports agencies with accurate, timely coding to help meet operational and reimbursement needs. If your organization is considering outsourced coding services, we would welcome the opportunity to discuss how we can help. Please don’t hesitate to reach out to us.
We are also offering a complimentary coding analysis for home health and hospice agencies. As part of this review, our team will evaluate up to 10 charts to help determine whether your current coding practices align with today’s coding requirements and identify opportunities for improvement.
Subscribe now to have our weekly Monday Minute with Melinda sent directly to your inbox. Click here to subscribe!