Healthcare Provider Solutions

ICD-10-CM implementation brought about many changes related to our coding world. However, several things remained the same and it is important to remember the following constant factors that have not changed:

  • All diagnoses MUST be verified by the physician and/or physician documentation.
  • Diagnoses MUST match across the chart – claim, POC/485 and the OASIS.
  • All coding MUST comply with the official ICD-10-CM coding guidelines.
  • DO NOT code symptoms if they are part of a disease process/condition unless you are instructed to do so by the coding guidelines. (Example: “use additional code for associated symptoms” see N40.1, Benign prostatic hyperplasia with lower urinary tract symptoms).
  • DO NOT list diagnoses if resolved.
  • Diagnoses MUST be accurate and should provide a clear picture of why the patient is receiving home care.
  • Sequencing of the diagnoses should reflect the seriousness of each condition and support the disciplines and services being provided.
  • The primary diagnosis is defined as the “chief reason the patient is receiving home care” and the diagnosis most related to the current home care POC.
  • Secondary diagnoses MUST have potential to impact the skilled services provided by the agency and should have an impact on the diagnoses addressed in the POC, if not directly treated.
  • Each ICD-10 code should be entered at its highest level of specificity.
  • “Unspecified” codes should be avoided. If your documentation received is not sufficient to establish a more specific code, consult with the physician.
    • If the HHGM payment model is implemented there are certain “unspecified” codes that will not be allowed as primary.

The ICD-10 coding on home care claims is of utmost importance. Entering information into your patient’s health history that will always be reflected in their medical record should not be taken lightly. Additionally, it is potentially a part of the case-mix weight which affects payment and MUST be correct and physician originated. All documentation must support your diagnoses submitted on the claim as true and accurate.

It is highly recommended that claims are coded by a certified home care coder. It is the responsibility of the assessing clinician to complete the comprehensive assessment and understand the patient’s overall medical condition and care needs before selecting and assigning diagnoses. The assessing clinician then determines the primary and secondary diagnoses. These diagnoses MUST be physician originated. It is acceptable for a coding specialist in the agency or outsourced entity to enter the actual numeric ICD-10 codes as long as the assessing clinician has determined the primary and secondary diagnoses. Agencies should have an OASIS correction policy in place and be able to provide it, as well as the paper trail/EMR trail involving all OASIS corrections if claims are submitted for audit review. Failure to have a certified coder examine the ICD-10 coding on claims leaves your agency at risk for denials, up-coding and/or leaving money on the table that is rightfully due.

Incorrect or inappropriate coding of claims can be one of the first elements that are reflected in the data as an aberrant billing practice by your agency to an auditor. It is vital that all diagnoses listed on the claim are supported in the documentation. Some coding issues that red flag your claims to an auditor and will possibly cause your claim to be overly scrutinized by a reviewer are:

  • The same diagnoses being present on multiple claims submitted, for multiple patients, all listed in the top six diagnoses and those being case-mix diagnoses. It is imperative that each patient is represented individually and according to the seriousness of their own disease processes. Thus preventing this issue from occurring.
  • Listing every diagnosis on your POC with an exacerbation and/or onset date as the date of recertification or admission to home care services. These dates also should be individualized with each diagnosis coded, and not generalized to one specific date. Especially the admission date or recertification date of home care services. Listing these exacerbation/onset dates is no longer a requirement, however, if the agency chooses to list them, they should be as accurate as possible.
  • Coding diagnoses that do not occur in the patient’s billing history, other than a code specific to home care such as an aftercare code or attention to code. Again, it is imperative these diagnosis, in regards to disease processes, originate with the physician and are supported in the documentation preventing this issue from occurring.
  • Using acute codes that are not appropriate for home care claims.
  • Coding manifestation codes as primary.
  • Coding superficial wounds inappropriately. Documentation should clearly support the wound as it is coded on the claim/OASIS/POC.
  • Contradicting documentation as to the type of wound/ulcer being treated. Always seek physician clarification if the documentation received regarding the type of ulcer is not clear. Example: Coding a diabetic ulcer and entering the same wound as a stasis ulcer on the OASIS.
  • Coding cancer diagnoses as acute (active) versus the history of. Verify that the documentation from the physician supports cancer as actively being treated and/or not eradicated and does not indicate the patient merely has a history of cancer.
  • Coding diagnoses that are not supported in the POC, medication profile and/or referral documentation.

Coding has always been important in home care, but is increasingly being scrutinized. Education, Education, Education needs to be happening with your coding staff. If the Home Health Groupings Model (HHGM) is approved as proposed Coding will be the only avenue of grouping your patients into a case mix grouping for reimbursement. Stay ahead of the game and ensure that your coding is up to par.