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September 2017

Coding NewsReduce re-hospitalizations by frontloading visits for your at-risk patients

Have a quality assurance nurse review all patients on start of care to make sure clinicians are using the right visit frequency for at-risk patients.

Mercy Health — Tiffin Home Care in Tiffin, Ohio, uses this strategy when frontloading visits for at-risk patients to address re-hospitalization rates as part of its QAPI project, according to Mandy Ritter, a manager with the agency.

Tiffin Home Care started frontloading in late 2016. The agency finished the year with a 14% readmission rate, but by June 2017, that rate had dropped to 6%.

The agency isn’t alone. Other home health agencies have seen a decrease in re-hospitalizations directly tied to frontloading at-risk patients.

According to data from Santa Barbara, Calif.-based Strategic Healthcare Programs (SHP), the number of home health visits in the first week after discharge from the hospital may influence readmission rates (See benchmark).

Frontloading has always been a best practice, but not all agencies do it, says Arlene Maxim, RN, vice president of Program Development with Quality in Real Time (QIRT) in Floral Park, N.Y.

About 20% of agencies may actually frontload patients, and some of them aren’t doing it well, she says.

At Tiffin Home Care, using a quality assurance nurse to review patients at start of care helps catch any patients that may be a good fit for frontloading while still early in the episode of care, Ritter explains.

Ritter adds that the quality assurance nurse can also help identify trends and opportunities for training, for instance, if a single clinician tends to have more readmissions he or she may be a good candidate for follow up one-on-one training on frontloading best practices.

Coding TipsFY2018 Coding Guidelines: “In” will be equivalent to “with” starting Oct. 1

Conditions linked in the alphabetic index by the word “in” should be considered related even without provider documentation of such, making it equivalent to the way conditions are now linked by the “with” convention, starting Oct. 1 when the FY2018 official coding guidelines go into effect.

This means that, for example, come Oct. 1 you’ll be able to assume a connection between anemia and chronic kidney disease (CKD) even in the absence of provider documentation, due to CKD being a subterm under the term “in (due to)(with)” in the alphabetic index listing for anemia.

In such a scenario you’ll assign D63.1 (Anemia in chronic kidney disease) immediately after a code from N18.- (Chronic kidney disease (CKD)) for the CKD stage, according to tabular instruction. Currently, you can only assign D63.1 when provider documentation specifically links anemia with CKD.

The updated guideline reads “[t]he word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List.” [I.A.15]

An exception to this convention occurs when a guideline specifically requires that the physician document a link between two conditions. In these cases, the code-specific guideline will take precedence over the convention, according to the guidelines posted to the CDC’s website Aug. 10.

Tool of the MonthAverage readmission rates by number of home health visits in first week

Patients who had two home health visits in the first seven days of care return to the hospital within 30 days 15.5% of the time, according to data provided Strategic Healthcare Programs (SHP) of Santa Barbara, Calif. In contrast, 36.4% of patients who had one home health visit in the first seven days return to the hospital within 30 days. The data reflects nearly 6.6 million episodes of care.

Readmission rates

August 2017

Coding TipHow to code hypertension due to diabetes

Code a patient who's been diagnosed by a physician with hypertension due to diabetes first with E11.59 (Type 2 diabetes mellitus with other circulatory complications) and then with I15.2 (Hypertension secondary to endocrine disorders).

This scenario is being seen among home health coders as are cases in which the patient also has chronic kidney disease (CKD) and heart failure.

A patient with diabetes, hypertension, stage 2 CKD and heart failure should be coded in the following manner: E11.59 (Type 2 diabetes mellitus with other circulatory complications), I15.2 (Hypertension secondary to endocrine disorders), E11.22 (Type 2 diabetes mellitus with diabetic chronic kidney disease), N18.2 (Chronic kidney disease, stage 2 (mild)) and I50.9 (Heart failure, unspecified), says Lisa Selman-Holman, HCS-D, principal of Selman-Holman Associates and the coding service CoDR — Coding Done Right in Denton, Texas.

The rationale behind the code choices is that the doctor diagnosed diabetes as the etiology for the patient's hypertension, which cancels its assumed relationship to the chronic kidney disease and the heart failure, Selman-Holman says. And since there's no specific code for hypertension as a manifestation of diabetes, E11.59 is the only available choice.

Remember, when there is no alternative etiology stated, a connection can be made between the patient's diabetes and chronic kidney disease due to its placement under "with" in the alphabetic index, according to coding guidelines. [I.A.15]

Coding NewsNew OASIS-C2 guidance manual includes one clinician rule clarification

CMS released the 2018 guidance manual for OASIS-C2 on August 4. The new guidance manual, which takes effect, Jan. 1, 2018, clarifies the "one-clinician rule," among other things.

The 2018 manual expands the role of allowed collaboration from only selected items to all OASIS data items integrated within the assessment.

Just as before, only one clinician may take responsibility for accurately completing a comprehensive assessment. Unlike before, however, the 2018 manual goes on to say that "collaboration with the patient, caregivers, and other health care personnel, including the physician, pharmacist, and/or other agency staff is appropriate and would not violate the one clinician convention."

View the full, updated manual online here.

Tool of the MonthSample OASIS submission tracker

Use the following tool to track each step of the OASIS assessment's submission process and stay within the 30-day deadline.

QA result
Pt medical record# Assessment date Date sent to QA Ready to submit Date sent to clinician Date clinician completed: Ready to submit
Note: If a date is in this column, the OASIS is ready to submit Note: If a date is in this column, the MR# will need to be monitored so that it is returned within 24-72 hours Note: If a date is in this column, the OASIS is ready to submit
Source: Jennifer Sandel, co-owner of Home Care Services Solutions, Battle Creek, Mich.

July 2017

Coding TipCarefully assess pain for non-verbal patients to improve 5-star ratings

It’s important to accurately assess pain for patients who are non-verbal or present other difficulties in communicating, because failure to do so can negatively impact Home Health Compare scores and 5-star ratings.

Proper assessment of pain will mean accurate and consistent answers to OASIS items M1240 (Pain assessment) and M1242 (Frequency of pain). It also could impact an agency’s pain outcomes. If clinicians aren’t assessing the patient for pain management, scores on your HHCAHPS could reveal you’re not doing a good job with pain management, says Diane Link, director of clinical services with BlackTree Healthcare Consulting in Conshohocken, Pa.

Doing a poor job at assessing pain in all patients, even those who can’t say aloud how they’re feeling, can impact future revenue. Pain is part of the 5-star ratings and poor marks could impact referrals and patient choice, Link says.

It’s fairly common for clinicians to encounter patients who can’t verbally communicate their pain level, explains Teresa Northcutt, senior consultant with Selman-Holman & Associates LLC in Denton, Texas. Non-verbal patients can range from those who have suffered a stroke or had throat surgery to those with cognitive impairment, such as dementia patients.

Trying to get people to accurately self-report pain is so important. "If I don’t know what your accurate level of pain is, I can’t help to better manage it," Northcutt says.

The key for non-verbal patients is finding the best scale for the patient, says Arlynn Hansell, owner of Therapy and More in Cincinnati.

For some non-verbal patients, rating on a scale of one to 10 can work. On the other hand, for some dementia patients, indicating on a scale of one to 10 may be confusing even if the patient is capable of showing an answer using non-verbal methods. For those patients, the Wong-Baker FACES Pain Rating Scale or the Rainbow Pain Scale may be something they can point to as a way to communicate their level of pain.

Coding NewsNew survey shows agencies’ use of tablets in patients’ homes continues to rise

For the past two years, Good Samaritan Home Health in Sioux Falls, S.D., has used tablets in patients' homes — saving clinicians 20 to 29 minutes per visit on average. Good Samaritan isn't alone in its use of tablets — a new DecisionHealth survey indicates use of the technology in the field continues to increase.

A 2017 DecisionHealth productivity survey shows 65% of agencies have clinicians that use tablets in patients’ homes, compared to only 58% of respondents to our 2015 survey.

And most respondents whose clinicians use tablets indicate the technology has helped with productivity. Many respondents say that with tablets, clinicians are able to document in the patient's home as opposed to later. Having all policies, procedures and other necessary documents at employees' fingertips on the tablets also saves time, says Renady Mohr, director of home health at the Sioux Falls location.

The continued shift toward tablet use in the home health industry is in part because the technology continues to progress, says Tim Rowan, editor of Home Care Technology Report in Colorado Springs, Colo. Over the past two years, advances in technology have allowed for smaller, lighter devices with longer battery life. Cellular plans for tablets also have become more attainable.

"It's become more practical and a little more cost effective," Rowan says of tablets. "Competition drove the price down and technology has brought the speed up."

Mohr can't imagine going back to relying heavily on paper. While there was some frustration among staff during the transition, triggered by a desire to get up to speed as quickly as possible, clinicians have embraced the tablets and how much time they save, Mohr says.

Tool of the MonthFeatured Benchmark: Home health agencies’ utilization of maintenance therapy, 2013 through 2016

Agencies’ use of maintenance therapy decreased in 2016 compared to 2015, according to data from Minneapolis-based ABILITY Network, Inc.

The data are representative of more than 3.5 million traditional Medicare episodes — at more than 2,000 provider locations nationwide — from January 2013 through December 2016. The data exclude outliers and low-utilization payment updates.

2016 2015 2014 2013
PT maintenance code (G0159) 0.94% 1.05% 0.82% 0.79%
OT maintenance code (G0160) 0.58% 0.80% 0.66% 0.48%
ST maintenance code (G0161) 0.31% 0.31% 0.27% 0.15%
Source: Minneapolis-based ABILITY Network, Inc.

June 2017

Coding TipFinal FY2018 ICD-10-CM contains hundreds of code changes not previewed in the proposed set

The final FY2018 ICD-10-CM codes include a total of 322 more changes than what was proposed in the April hospital inpatient prospective payment system (IPPS) rule. There are 360 new, 142 deleted and 226 revised diagnosis codes in the final FY2018 update posted to CMS’ website June 13.

The final update includes 72 new non-pressure chronic ulcer codes that will allow coders to specifically capture wounds that have penetrated into muscle or bone tissue, but that have not caused necrosis.

Currently, non-pressure chronic ulcers that involve muscle or bone but in which there’s no evidence of necrosis cannot be captured with the codes that describe muscle or bone necrosis, according to Coding Clinic guidance issued in letters to an individual that were received on July 28 and Sept. 18, 2015.

But this guidance and the expert advice to code these wounds as having only penetrated fatty tissue has unintentionally resulted in less-than-accurate records, says Michelle Horner, HCS-D, assistant director of quality operations for Floral Park, N.Y.-based coding outsourcer Quality in Real Time.

The addition of these new codes was formally requested by DecisionHealth and the Association of Home Care Coding and Compliance (AHCC) in a proposal that was discussed at the March 2016 meeting of the ICD-10 Coordination and Maintenance Committee.

Additionally, a new subcategory (I50.8, Other heart failure), new sub-subcategory (I50.81, Right heart failure) and nine new codes for heart failure, including I50.84 (End stage heart failure) will make their way into the code set on Oct. 1.

Also, new inclusion terms on heart failure codes, including “Heart failure with preserved ejection fraction [HFpEF]” on subcategory I50.3- (Diastolic (congestive) heart failure), will help guide code choices based on diagnostic statements.

Additional noteworthy changes include new myocardial infarction codes, expansion of the enterocolitis due to Clostridium difficile subcategory, a new ketoacidosis in type 2 diabetes subcategory, the return of spinal stenosis with neurogenic claudication diagnoses and new substance abuse in remission codes.

Look for more coverage in the next issue of Diagnosis Coding Pro for Home Health.

Coding NewsTraining materials, answers from recent CMS provider training now available

Presentations and associated scenario answers from the Home Health Quality Reporting Program (HHQRP) provider training conducted by CMS in Baltimore on May 4 are now available for download.

The documents posted on the HHQRP Training website include scenarios and answers provided in slide presentations during the training as well as a case study with related information and answers.

Find the training documents at the bottom of the following website: http://go.cms.gov/2eA0xZn.

Ultimately CMS plans to release official OASIS Q&As from the Baltimore training. It is unclear when that might happen. In late February, CMS posted OASIS Q&As that came from its November 2016 HHQRP training in Dallas.

Tool of the MonthFeatured Tool: FY2018 final code changes by chapter

Use this chapter-by-chapter breakdown of where you can find the new, revised and deleted codes for FY2018 to prepare for the changes coming Oct. 1, 2017.

Chapter New Revised Deleted
1: Certain infectious and parasitic diseases (A00-B99) 2 0 1
2: Neoplasms (C00-D49) 7 0 2
3: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) 0 0 0
4: Endocrine, nutritional and metabolic diseases (E00-E89) 5 0 1
5: Mental, behavioral and neurodevelopmental disorders (F01-F99) 10 1 0
6: Diseases of the nervous system (G00-G99) 3 0 0
7: Diseases of the eye and adnexa (H00-H59) 55 7 8
8: Diseases of the ear and mastoid process (H60-H95) 0 0 0
9: Diseases of the circulatory system (I00-I99) 19 18 1
10: Diseases of the respiratory system (J00-J99) 0 1 0
11: Diseases of the digestive system (K00-K95) 20 0 5
12: Diseases of the skin and subcutaneous tissue (L00-L99) 72 0 0
13: Diseases of the musculoskeletal system and connective tissue (M00-M99) 5 8 1
14: Diseases of the genitourinary system (N00-N99) 15 6 1
15: Pregnancy, childbirth and the puerperium (O00-O9A) 40 0 4
16: Certain conditions originating in the perinatal period (P00-P96) 8 0 3
17: Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 6 2 2
18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) 3 0 0
19: Injury, poisoning and certain other consequences of external causes (S00-T88) 12 176 112
20: External causes of morbidity (V00-Y99) 54 2 0
21: Factors influencing health status and contact with health services (Z00-Z99) 24 4 1
Source: DecisionHealth analysis of the final FY2018 ICD-10-CM new, revised and invalid codes

May 2017

Coding TipAgencies in new survey identify HHCAHPS improvement as their top QAPI project

Improving on HHCAHPS results is the number one quality assurance performance improvement (QAPI) project agencies have made in the past year or plan to implement in the near future.

That’s according to 317 respondents on a Home Health Line survey about agencies’ preparations for the revised Home Health Conditions of Participation (CoPs).

Although making specific efforts to reduce rehospitalizations might seem like it would be the top response — it came in second — it makes sense that HHCAHPS efforts ranked first, says Chris Attaya, vice president of business intelligence for Santa Barbara, Calif.-based survey vendor Strategic Healthcare Programs (SHP).

HHCAHPS 5-star ratings have been available since January 2016. The cutoffs in star ratings are so close that it might only take improving one patient’s experience to suddenly shift your agency from three to four stars, for example, says Lori Moshier, president of HHCAHPS vendor Novaetus in Novi, Mich.

The HHCAHPS survey also is an important part of value-based purchasing, which began in January 2016. Five of 17 measures used in value-based purchasing come from the HHCAHPS.

Plus, health systems pay close attention to patient satisfaction results, Attaya says. And industry experts contend that patients with better care experiences are likely to achieve better outcomes.

“Our agency is part of a hospital as well, so there’s a huge focus on customer satisfaction,” notes Debra Everhart, administrator of HomePlus in Elkins, W.Va. “We’re a small agency and we get about 25 (surveys) back each month, and all it takes is one to really knock you down.”

Despite this, agencies in recent years have not improved overall on the HHCAHPS survey.

In January 2017, the score in the domain “Percent of patients who reported that their home health team gave care in a professional way” was 88. And the percent of patients reporting that the home health team communicated well with them was 85.

Agencies nationwide received the same scores on those domains in January 2016, January 2015 and January 2014.

Get all the Hospice coding instructions you need in one powerful tool! Learn how the Coding Center can empower your hospice to submit clean claims for fast and full reimbursement. Join us on Wed., May 24, 2017 at 1:00 PM ET for a FREE demo to see it in action. Save time and increase accuracy with this user-friendly, web-based resource - give us just 30 minutes to show you how!


Coding NewsHospice coding practices improving, lowering risk of audits

Not a single hospice submitted a claim in FY2016 that contained only one diagnosis code.

Data reported in the FY2018 proposed hospice payment rule indicates that hospices are acting in compliance with CMS’s repeated request that they code every unresolved diagnosis a hospice patient has regardless of its relation to the terminal one.

“Analysis of FY 2016 hospice claims show that 100 percent of hospices reported more than one diagnosis, with 86 percent submitting at least two diagnoses and 77 percent including at least three diagnoses,” according to the rule released April 28.

This is a huge improvement over FY2015 when 37% of hospices assigned only one diagnosis, which was an improvement from 49% in FY2014.

Additionally, the non-specific diagnoses debility (R53.81) and adult failure to thrive (R62.7), as well as unspecified dementia (F03.9-), were not listed among the top 20 most commonly assigned principal diagnosis codes, according to the rule. This is further evidence that hospices are acting in compliance with the another oft-repeated hospice directive to avoid using such overly vague diagnoses in the primary position.

Tool of the MonthFeatured Benchmark: Top 10 primary hospice diagnoses in FY2016

The top 10 most often assigned diagnoses in the primary position on hospice claims for FY2016, according to the FY2018 proposed hospice payment rule.

Rank ICD-10 Code Code Title
1 G30.9 Alzheimer's disease, unspecified
2 I50.9 Heart failure, unspecified
3 J44.9 Chronic obstructive pulmonary disease, unspecified
4 C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
5 G31.1 Senile degeneration of brain, not elsewhere classified
6 G20 Parkinson's disease
7 I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
8 J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
9 G30.1 Alzheimer's disease with late onset
10 I67.2 Cerebral atherosclerosis

March 2017

Coding NewsGet supervisors into the field more to improve retention, satisfaction

Pay close attention to how clinical supervisors' time is spent. Consider whether certain tasks to move documents through the revenue cycle could be performed instead by clerical staff or quality improvement staff.

Finding ways to get clinical supervisors into the field more often has helped Vanderbilt Home Care Services, Inc., in Nashville, Tenn., better retain clinicians and significantly increase patient satisfaction scores, says Katie Koss, the agency's vice president.

By changing to a new electronic medical records (EMR) system, rejiggering roles and shifting most meetings to one day per week, Vanderbilt has been able to send clinical supervisors into the field about 25% to 30% of the time they're at work.

"There was not a negative financial impact on any of this," Koss says of the agency's efforts to free up supervisors. "In fact, it made our clinician productivity increase."

Indeed, it's vital for agencies to have clinical supervisors develop better relationships with the clinicians who work for them and provide them proper education in the field, and freeing up clinical supervisors will help with that, says Cindy Campbell, director of operational consulting for Fazzi Associates of Northampton, Mass.

Prior to 2015, the agency only sent supervisors into the field twice a year to conduct supervisory visits.

Among the times when supervisors now go in the field: When a patient requires a skill the clinician hasn't used in a while, after a patient calls the agency expressing a concern about his or her care/treatment or after the agency identifies the need following case conferencing or a review of documentation.

"To free up time for clinical supervisors, we shifted roles, allowing those supervisors to spend less time dealing with task-related issues and have quality partners to give them cues on employee work," Koss says. "Additionally, we added an LPN to the office to triage all patient and clinician calls so that the clinical supervisors only receive the calls that need to be escalated to their levels."

Vanderbilt also now uses Wednesdays as a heavy meeting day, Koss says. This frees up other days for supervisors to go into the field.

Coding NewsStay in compliance with the new joint replacement coding rules

You should only assign a code from the Z47.3- (Aftercare following explantation of joint prosthesis) when the joint replacement complication has completely resolved, the old joint has been removed and a new one has been placed in a planned, staged procedure.

In any other situation in which a joint replacement has been performed to treat a fracture, or when the patient is receiving another joint prosthetic after having one removed due to a still-resolving complication, such as a mechanical loosening, an aftercare code is not appropriate, according to Q3 2016 Coding Clinic guidance.

Rather, in these cases, you’d assign the fracture code or the code for the specific complication with the appropriate seventh character to indicate whether the patient is still receiving active treatment, according to official coding guidelines and Q3 2016 Coding Clinic guidance. [I.C.19.c] [I.C.19.c.1]

Part of the reasoning for continuing to assign the fracture code in these scenarios is that there are clinical differences between fracture-induced joint replacements and elective joint replacements, with the former potentially requiring more intensive rehab, according to the Coding Clinic.

Tool of the MonthFeatured Benchmark: Nationwide turnover rates for home health employees on rise

Turnover rates for all home care employees crept toward 20% in 2016, though not all positions saw an increase from 2015, according to the more than 1,900 agencies participating in the Hospital & Healthcare Compensation Service's 2016-2017 Home Care Salary & Benefits Report.

Type of employee 2016 national turnover rate 2015 national turnover rate
All employees 19.2% 18.1%
RNs 19.1% 19.9%
LPNs 17.5% 11.5%
Aides 24.9% 18.0%
Therapists 18.0% 10.6%

January 2017

Coding NewsUse depression assessment tools to reduce patient rehospitalization rates

Train clinicians how to ask whether patients have lost interest in activities or if they have been feeling sad. These questions will lead to more accurate assessments and better depression treatment that can lower your rehospitalization rates and improve your star ratings.

Because some clinicians may feel uncomfortable asking patients about emotional health, have clinicians practice asking and answering the inquiries on the depression scales so they can become more at ease with the questions and learn how to speak more naturally to patients, says Katherine J. Vanderhorst, vice president at C&V Senior Care Specialists, Inc., a behavioral health consulting firm in Williamsville, N.Y.

Patients identified in depression screening as having a potential mental health issue and who suffer from diabetes, congestive heart failure or chronic obstructive pulmonary disease are prone to rehospitalization so it's important to identify this early on, Vanderhorst adds.

Another way to rephrase questions to encourage patients to open up is to ask if their condition has ever made them feel overwhelmed, Vanderhorst says. And ask if patients have ever been treated for depression. These questions might help patients open up about a difficult topic.

Use a depression screening tool that has been scientifically tested in a population with characteristics similar to the patient being assessed. Different tools are better for patients depending on their ages. The PHQ-9 is the better tool for adults under age 65, Vanderhorst says. She says her agency prefers the Geriatric Depression Scale — Short Form (GDS) for their patients over age 65. The questions that require more than a yes or no response are difficult for adults with cognitive problems, Vanderhorst explains. The GDS has 15 questions that ask seniors questions about whether they are satisfied with life or are in good spirits.

OASIS-C2 is here!
Completing the OASIS is complicated and open to interpretation. Get all the OASIS content you need in one powerful tool! Learn how the Coding Center can empower your home health agency to submit clean claims for fast and full reimbursement. Join us on Thurs., Feb. 16, 2017 at 1:00 PM ET for a FREE demo to see it in action. OASIS accuracy is your key to becoming a 5-star agency, so don't get left behind!


Coding NewsCMS expands pre-claim reviews to Florida, starts Round 2 of probe reviews

In the last two weeks of December CMS announced its plans to continue with two claims-review projects that could spell trouble for home health agencies. First off, the nationwide probe-and-educate reviews that occurred in 2016 will resume, which will add further pressure on the home health industry. And secondly, pre-claim reviews will start in Florida in April.

Round 2 of the home health probe-and-educate review began Dec. 15 and will end in about a year, CMS said in MLN Matters article SE1635, posted Dec. 16. All home health agencies with two to five claims in error during the probe's first round will receive five more ADRs from Medicare Administrative Contractors (MACs) as part of the next round, CMS says.

Although CMS has not released data at this point on the probe's first round, about 61% of respondents to a question on HHL's 2017 Trends Survey said their agency received at least two denials.

CMS' five-state pre-claim review demonstration, which already has caused consternation for Illinois agencies, is expanding to Florida for services beginning on or after April 1, 2017, according to a Dec. 19 CMS press release.

Tool of the MonthFeatured Tool: Use this tool to improve outcomes, reduce readmissions

The Geriatric Depression Scale (GDS) can be used to assess whether a patient has depression and needs further evaluation and interventions. This tool is among several provided by the Visiting Nurse Associations of America’s (VNAA) Blueprint for Excellence training module on depression screening for home health.

Score 1 point for each bolded answer. A score of 5 or more suggests depression.
1 Are you basically satisfied with your life? Yes No
2 Have you dropped many of your activities and interests? Yes No
3 Do you feel that your life is empty? Yes No
4 Do you often get bored? Yes No
5 Are you in good spirits most of the time? Yes No
6 Are you afraid that something bad is going to happen to you? Yes No
7 Do you feel happy most of the time? Yes No
8 Do you often feel helpless? Yes No
9 Do you prefer to stay at home, rather than going out and doing things? Yes No
10 Do you feel that you have more problems with memory than most? Yes No
11 Do you think it is wonderful to be alive now? Yes No
12 Do you feel worthless the way you are now? Yes No
13 Do you feel full of energy? Yes No
14 Do you feel that your situation is hopeless? Yes No
15 Do you think that most people are better off than you are? Yes No
Total Score:

 
Ultimate Training

Get regional OASIS-C2 & ICD-10 training in a city near you! It’s no big secret. Coders and clinicians who are well-trained and informed on these changes remain compliant and agencies get the proper reimbursement they are entitled. Where do they get that training? At DecisionHealth’s Ultimate Coding & OASIS-C2 Training Series. Get in-depth and hands-on training led by the top HCS-D & HCS-O certified experts!


Learn More


December 2016

Coding NewsLook to laterality when your agency documents, codes fractures

When gathering the proper documentation for injury codes in ICD-10 related to fractures, make sure intake and field clinicians obtain information about the timing of the encounter and whether it is open or closed to code the seventh character.

This information should be obtained by intake employees or clinicians from history and physical and operation reports from the hospital or other referral sources like skilled nursing facilities (SNF), says Jean Bird, HCS-D, regional utilization review supervisor for Gentiva in Fall River, Mass.

Doing so is critical in order to code to the highest degree of specificity related to traumatic fractures and avoid auditors scrutinizing your plans of care.

Injury codes related to a traumatic fracture are coded to the original injury with a seventh character, says Judy Adams, HCS-D, president of Adams Home Care Consulting in Durham, N.C. The seventh character also can describe if there is normal healing or a complication present.

Further, if the fracture is open, meaning the bone has penetrated through the skin, intake or field clinicians will have to obtain the Gustilo open fracture grade that rates tissue damage related to the fracture to code the appropriate seventh character, Bird says. The Gustilo grade has to be assigned by the physician, and this information may not be available in medical information sent to home health currently; intake or clinicians will need to get this from the doctor to code accurately, Bird says.

Clinicians also will need to document healing complications — like nonunion or malunion — for such fractures that may not develop until months after an operation, in order to accurately code the seventh character for S72.-, she says. For example, option ‘K’ will be used to indicate a subsequent encounter for a closed fracture with nonunion, while option ‘G’ will be used for a subsequent encounter for a closed fracture with delayed healing.

The OASIS and its guidance is changing on Jan. 1, 2017. Will you be ready?
Completing the OASIS is complicated and open to interpretation. Get all the OASIS content you need in one powerful tool! Learn how the Home Health Coding Center can empower your home health agency to submit clean claims for fast and full reimbursement. Join us on Wed., Dec. 14, 2016 at 1:00 PM ET for a FREE demo to see it in action. OASIS accuracy is your key to becoming a 5-star agency, so don't get left behind!

 

Can’t make it on the 14th? Contact a Product Consultant to arrange a custom demo.


Coding NewsElection fallout: Fate of face-to-face requirement uncertain

The Republican-controlled Congress and White House won’t be able to erase the Affordable Care Act (ACA) in its entirety, House Republican aides suggest, which means the home health industry may have to lobby on its own to erase the ACA’s face-to-face requirement.

Democrats still have enough Senate votes to prevent majority Republicans from cutting short a certain Democratic filibuster of an ACA repeal, as has occurred with previous GOP attempts. The only way around the impasse for Republicans will be to attack the health coverage law using a budget reconciliation bill as the vehicle. Budget reconciliation bills need only 51 votes to pass as opposed to the 60 needed to shut off debate.

At the same time, however, budget reconciliation bills only can deal with legislation that has “a direct impact on federal revenues or outlays,” a definition that excludes the face-to-face provision but makes the well-funded Center for Medicare and Medicaid Innovation (CMMI) a possible target, notes Washington, D.C. attorney John Williams, who monitors congressional actions for the law firm Hall, Render, Killian, Heath & Lyman.

To the National Association for Home Care & Hospice (NAHC), though, the possibility of killing the face-to-face requirement outright remains.

The election has made both Democrats and Republicans more willing to discard such unnecessarily burdensome regulations, making it easier to lobby for face-to-face relief, reasons Bill Dombi, NAHC’s vice president for legal affairs.

Tool of the MonthFeatured Tool: Examples of compliant face-to-face encounter information

You can help physicians fill out the face-to-face form correctly on the first try by giving them this simple tool. The tool, which was created by Baptist Home Health Care in Jacksonville, Fla., provides physicians with common examples of conditions that would support home health, as well as clinical reasons why a patient would be homebound.


November 2016

Coding NewsUse caution with alcohol-related non-compliance codes

Do not assign Z91.19 (Patient’s noncompliance with other medical treatment and regimen) simply because you see that a patient with alcoholic liver disease continues to drink alcohol, or you could be risking claims denials.

Rather, a patient’s noncompliance is something that must be confirmed by the physician and the clinician, and for which there needs to be written documentation, says Trish Twombly, HCS-D, senior director for DecisionHealth in Gaithersburg, Md.

Furthermore, not all physicians consider continuing to drink with alcoholic liver disease to be noncompliance, says Brandi Whitemyer, HCS-D, an independent home health and hospice consultant in Canton, Ohio.

Hasty assignment of noncompliance codes in these cases is risky because Medicare requires that agencies discharge non-compliant patients, Twombly says.

However, there is no firm guideline on when discharges should happen and most agencies take it on a case-by-case basis after reporting the non-compliance to the physician and documenting the physician’s response, she says.

Patients get at least “one strike” before they’re classified as noncompliant at FirstHealth Home Care in West End, N.C., says Regenia Simmons, HCS-D, the agency’s coding and OASIS specialist.

Simmons also says that she does not code noncompliance without a documented pattern of failure to follow the prescribed treatment regimen.

Discharge for noncompliance is usually a last-resort option, such as when a patient has been recertified multiple times for severe and worsening alcoholic cirrhosis but resists rehabilitation options and continues to drink heavily, Twombly says.

A patient who is abusing alcohol after receiving a liver transplant also may be considered noncompliant because patients are required to quit drinking in order to be eligible for transplantation, Whitemyer says.

Attention Home Health Coding Center Users!
Join Coding Center Product Manager Steven Brust, HCS-D, Wednesday, November 30 @ 2pm ET for a Tips & Tricks session where we'll show you how easy it is – using the application – to quickly determine the appropriate GI and liver codes and where to find the official and expert guidance to properly assign and sequence them.


Coding NewsCMS adds 4 new measures tied to payments for all agencies

CMS announced in the 2017 PPS final rule that it will add four measures to the list of those that will be tied to agencies’ payments in 2018. Agencies that don’t report the following measures will receive a 2% reduction in payments. These four measures were selected to help meet requirements of the IMPACT Act. Those measures are:

  • Potentially preventable 30-day post-discharge readmission measure for post-acute care home health quality reporting program;
  • Total Medicare spending per beneficiary — post-acute care home health quality reporting program;
  • Discharge to community — post-acute care home health quality reporting program; and
  • Drug regimen review conducted with follow-up for identified issues — post-acute care home health quality reporting program.

Of the four measures, three will automatically be calculated by CMS based on claims, says Mary Carr, vice president for regulatory affairs, for the National Association for Home Care & Hospice (NAHC). The other measure — involving the drug regimen review — is information agencies already are collecting.

Tool of the MonthFeatured Scenario: Alcoholic cirrhosis with ascites

A 77-year-old man comes to home health with a diagnosis of alcoholic cirrhosis with ascites. He also has type 2 diabetes. The liver disease is the focus of care. He has a diagnosis of alcoholism but the medical record says it is in remission and he is not continuing to drink.

Primary and Secondary Diagnoses M1025
Additional diagnoses
M1021a: Alcoholic cirrhosis of liver with ascites K70.31    
M1023b: Alcohol dependence, in remission F10.21    
M1023c: Type 2 diabetes mellitus without complications E11.9    

Rationale:
The alcoholic cirrhosis is the focus of care and is therefore coded primary. Because he also has ascites, the combination code indicating the presence of ascites is assigned. His alcoholism is documented was documented as in remission, making F10.21 the appropriate code. Diabetes is an important comorbidity that always must be coded when present.

Increased scrutiny means your hospice's revenue is always at risk, and only correct coding will keep your claims compliant and auditors at bay. Learn how the Coding Center can empower your hospice to submit clean claims for fast and full reimbursement. Join us on Tues., Nov. 29, 2016 at 1:00 PM ET for a FREE demo and see how easy it can be to accurately code your claims the first time, every time. See it in action!


October 2016

Coding NewsSupervisory visits ensure home health agencies maintain high quality and standards

Administrators should use supervisory visits for nurses and therapists — in addition to aides — as a strategy for communicating clear expectations for staff. Such visits will ensure agency standards are met and patients are receiving high quality care.

Regulatory requirements for supervisory visits for therapy and nursing staff can be different than those for home health aides.

Supervisory visits by Bellin Home Health Agency, Green Bay, Wisc., focus on making sure patients are safe and are built around the Joint Commission’s National Patient Safety Goals, says Emily Nelson, RN, quality regulatory coordinator.

Supervisory visits are performed by supervisory staff in the same discipline at least once annually but may occur more frequently. “We’re regulated by the Joint Commission, but it’s really what the agency dictates,” she says.

Nelson says whether supervisory visits for nurses and therapists are performed are left to the discretion of the agency. She says they are not mandated by state or federal rules.

For aides, Nelson says, her agency conducts supervisory visits every two weeks in accordance with CMS regulations. CMS requires supervisory visits of aides as a Condition of Participation in Medicare. CMS mandates that nurses or therapists perform onsite visits every two weeks to oversee the work performance of home health aides.

“It ensures that the aide is completing what tasks are on their assignment sheet, and the patient is receiving that care,” says consultant Rebecca Friedman Zuber, formerly the director of Illinois’ state survey office. Documentation must clearly show a required visit was conducted, she says.

G0229 (Supervisory visits if skilled care no less than once every two weeks) was the ninth-most common standard-level deficiency in 2015, yielding 306 citations, data CMS provided DecisionHealth show. It’s important, in part, to avoid getting standard-level deficiencies because multiple or repeat standard-level deficiencies can result in new sanctions such as civil monetary penalties.

Attention Home Health Coding Center Users!
Join us Tuesday, October 27 @ 2pm ET for a Tips & Tricks session where we'll show you how easy it is – using the application – to quickly determine the appropriate glaucoma, blindness and hearing loss codes.


Coding NewsCMS introduces new wound guidance in OASIS-C2

When a Stage 3 or Stage 4 wound has epithelialized, clinicians should no longer report it as an unhealed pressure ulcer. The impact of that could be a reduction of hundreds of dollars per episode.

That’s one of the many guidance changes included in CMS’ OASIS-C2 guidance manual set to take effect Jan. 1, 2017.

Current OASIS-C1 guidance requires that closed stage 3 and 4 pressure ulcers, which are never considered “healed,” just closed, are captured on the assessment. But in OASIS-C2, unhealed pressure ulcers are the only wounds that will be recorded as a 2, which is sure to cause confusion for clinicians used to recording closed or healed wounds, says Brandi Whitemyer, HCS-D, an independent consultant in Canton, Ohio.

Categorizing a Stage 3 epithelialized wound as closed will mean a significant decrease in reimbursement, Whitemyer says. M1324 (Stage of the most problematic unhealed pressure ulcer that is stageable) is worth up to 31 clinical case-mix points for an early, high-therapy episode.

While a Stage 2 ulcer is limited to epithelial loss only, a Stage 3 ulcer, even when closed, includes loss of deeper tissue structure, and even when closed only has regained 70% of tensile strength. Healing Stage 3 wounds remain a risk for breaking down, Whitemyer says.

Tool of the MonthFeatured Benchmark: How much agencies will spend on CoPs training

Nearly half of the 312 respondents to a question on Home Health Line’s Proposed CoPs survey plan to spend in excess of $2,500 in the next year on training to prepare for the revised Home Health Conditions of Participation (CoPs).

Source: Home Health Line's CoPS Survey

Is your agency overwhelmed by the new ICD-10 code changes? Increased scrutiny will put your agency's revenue at risk if you can't master the code changes. Improve your team’s accuracy and productivity with the Home Health Coding Center — the only tool your coding and OASIS staff will need to submit clean claims for fast and full reimbursement. See it for yourself! Sign up now for a FREE demo on Thurs., November 10, 2016 at 1:00 PM ET.


September 2016

Coding NewsLearn when to properly assign A vs. B infectious organism codes

Never assign A49.02 (Methicillin resistant Staphylococcus aureus infection, unspecified site) to capture a MRSA organism that’s caused acute bronchitis in a COPD patient, or you could be putting your claims at risk.

Instead, assign B95.62 (Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere) directly following the code for the lung condition, J44.0 (Chronic obstructive pulmonary disease with acute lower respiratory infection).

Use codes from the B95.-, B96.- or B97.- categories when a patient has an infection that was caused by a disease that is classified in a chapter other than Chapter 1 (Certain infectious and parasitic diseases), according to official coding guidelines [I.C.1.b].

Conversely, a MRSA infection caused by a condition that is classified to Chapter 1, like sepsis, would be captured by a code beginning with the letter “A.” In this case, it would be A41.02 (Sepsis due to Methicillin resistant Staphylococcus aureus).

Tip: “A” codes include the result of the infection, like sepsis, within the code title, while “B” codes always indicate that the infection has caused another disease or condition that’s captured with a code found in another chapter. This means that “A” codes can stand alone to fully describe a patient’s infection, but “B” codes always require another code to be sequenced before them. For this reason, an “A” code can be sequenced in the primary position if the situation so dictates, but a “B” code cannot.

It’s important to learn how to use these codes correctly, as assigning the wrong infectious organism codes, and/or sequencing them incorrectly, could put your claims at risk as CMS has become more stringent about rejecting claims that don’t adhere to coding guidelines.

Coding TipFY2017 coding guidelines confirm "with" guidance

The FY2017 official coding guidelines confirmed that the classification presumes a causal relationship between two conditions linked by the term "with" in the Alphabetic Index or Tabular List. These conditions should be coded as related even without provider documentation directly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not linked by the relational terms in the classification, provider documentation must link the conditions in order to code them as related.

Furthermore, the classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term “with” in the Alphabetic Index. For hypertension and conditions not specifically linked by relational terms such as “with,” “associated with” or “due to” in the classification, provider documentation must link the conditions in order to code them as related, according to the 2017 coding guidelines, which take effect Oct. 1, 2016.

Attention Home Health Coding Center Users! Join us Tuesday, September 27 @ 2pm ET for a Tips & Tricks session where we'll show you how easy it is – using the application – to quickly determine which conditions are linked in ICD-10 through the term "with" in the Alpha Index.


Tool of the MonthFeatured Scenario: Cellulitis with E. coli

A 73-year-old woman comes to home health with a primary diagnosis of cellulitis on her groin that is infected with E. coli and is being treated with IV antibiotics. She also has diabetes and hypertension.

Primary and Secondary Diagnoses M1025
Additional diagnoses
M1021a: Cellulitis of groin L03.314    
M1023b: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere B96.20    
M1023c: Type 2 diabetes mellitus without complications E11.9    
M1023d: Essential (primary) hypertension I10    
M1023e: Encounter for adjustment and management of vascular access device Z45.2    
M1023f: Long term (current) use of antibiotics Z79.2    

Rationale:
The E. coli infection caused cellulitis in the patient’s groin, which is classified to Chapter 12 (Diseases of Skin and Subcutaneous Tissue). Therefore, the appropriate code to capture the infecting organism is B96.20. Code B96.20 is sequenced after the disease that it is causing, the cellulitis, in accordance with coding guidelines.

The patient is receiving IV antibiotics and therefore Z45.2 and Z79.2 are coded to capture this. As important comorbidities, her diabetes and hypertension are also coded.

August 2016

Coding NewsHospice final rule increases payments by $350 million, creates two quality measures

Medicare’s hospice payments, adjusted for inflation and other factors, will rise an estimated 2.1% in 2017, according to the final hospice payment rule. And CMS will begin collecting data on two new quality measures starting in April 2017. The final rule will become effective Oct. 1, a CMS fact sheet about the rule states.

For routine home care, the payment rate for days 1-60 will be $190.55 in 2017, compared to $186.84 in 2016. For days 61 and beyond, payments will be $149.82 in 2017, compared to $146.83 in 2016. The service intensity add-on (SIA) payment rate will be $40.19 per hour.

The final rule also creates two new quality measures. Data collection for the measures will begin April 1, 2017.

A hospice and palliative care composite process measure will measure the percentage of patients who receive the following processes: patients treated with an opioid who are given a bowel regimen, pain screening, pain assessment, dyspnea treatment, dyspnea screening, treatment preferences, and beliefs/values addressed (if desired by the patient).

The second measure that CMS will introduce assesses the percentage of patients receiving at least one visit from RNs, physicians, nurse practitioners or physician assistants in the last three days of life. And the measure assesses the percentage of patients receiving at least two visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses or hospice aides during the last seven days of life.

Increased scrutiny has put your hospice’s revenue at risk, and only correct coding will keep your claims compliant and auditors at bay. You need the Home Health Coding Center to quickly pinpoint the correct ICD-10 code, plus the guidance, tips and sequencing instructions you need to assign it correctly all on one page. See it for yourself! Click here to sign up for a FREE demo on Thurs., August 25, 2016 at 1:00 PM ET.


Coding TipCode injury, not aftercare, when joint replacement treats a fracture

Continue to assign the injury code, for example S72.001D (Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing), for a patient who underwent a joint replacement to treat a hip fracture.

The aftercare code Z47.1 (Aftercare following joint replacement surgery) is not appropriate in these types of scenarios, confirmed Nelly Leon-Chisen, director of coding and classification for the American Hospital Association, which publishes the Coding Clinic’s quarterly updates. Leon-Chisen confirmed this guidance during her session at DecisionHealth’s 14th annual Home Health Coding Summit.

This guidance amounts to a substantial change from how the care of joint replacements done to treat fractures is coded. Previous wisdom held that once the fractured bone is surgically excised and replaced with a prosthetic joint, the fracture no longer exists and the aftercare code is the only logical choice.

Tool of the MonthFeatured Tool: Aftercare vs. Injury Tool

Have your coding staff reference this tool to help guide their ICD-10 code selection when deciding between assigning an aftercare code or a 7th-character code for a trauma wound or musculoskeletal injury.

Trauma wound Injury. Assign code from Ch. 19, with appropriate 7th character.
Trauma wound,
surgically repaired
Injury. Assign code from Ch. 19, with appropriate 7th character.
Musculoskeletal injury sustained through trauma Injury. Assign code from Ch. 19, with appropriate 7th character.
Musculoskeletal injury resulting from trauma, surgically repaired Injury. Assign code from Ch. 19, with appropriate 7th character.
Musculoskeletal injury resulting from disease process, surgically repaired Aftercare. Assign appropriate code from Z47.- (Orthopedic aftercare).

More than 3,000 ICD-10 code changes and a complete overhaul of the coding guidelines all take effect Oct. 1. The margin for error is getting wider, so don’t get left behind!

Ultimate Training

DecisionHealth’s Ultimate Coding & OASIS Training Series is back this fall! Join us in a city near you and get the in-depth, hands-on ICD-10 and OASIS-C2 education led by the top home health experts including Judy Adams, Lisa Selman-Holman and Trish Twombly!


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July 2016

Coding NewsCoding Clinic confirms “with” allows for assumptions without physician confirmation

You’ll now code E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified) for a patient who has diagnoses of diabetes and neuropathy, even if there’s no specified confirmatory link in the record, according to the Q2 2016 Coding Clinic update.

The ICD-10 classification assumes a relationship between the two conditions because “neuropathy” is listed under the subterm “with” in the index listing for “diabetes.”

The subterm “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List, the Coding Clinic states in its Q2 update released June 3.

In fact, any condition listed under a subterm “with” in the Index should be interpreted as linked to the main term when both conditions are present, according to the Q2 2016 Coding Clinic.

“The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular,” the Coding Clinic clarified.

This guidance amounts to a 180-degree shift from previous instruction which stipulated that conditions that are potential manifestations of diabetes, such as neuropathy, retinopathy and chronic kidney disease, could not be coded as such unless the physician specified a link.

While coding experts largely see a strong medical basis to assume a connection between diabetes and conditions like CKD and PVD, they see trouble ahead in areas that are less clear cut, such as which diagnoses should be included in non-specific codes like E11.59 (Type 2 diabetes mellitus with other circulatory complications).

Whether this new Coding Clinic guidance will lead to higher, lower, or unchanged levels of reimbursement is a question that will answered over time. However, experts are apprehensive about how CMS will react if there is an abrupt shift in coding patterns resulting in much bigger payouts to home health.

The latest ICD-10 coding guidance in a simple online tool!
With the Home Health Coding Center, DecisionHealth provides all the official guidance with plain-English interpretation from nationally recognized home health coding experts – updated in real-time! There's no better way to ensure full reimbursement and increased accuracy! But don't take our word for it. See it in action and sign up for a free demo.


Coding TipCMS adopts NPUAP wound guidelines in OASIS-C2 manual

Home health agencies got a first look at the OASIS-C2 guidance manual that updates the data set scheduled to go into effect beginning Jan. 1, 2017, for all assessments.

CMS, in guidance released June 28, says that agencies may adopt in their clinical practice and documentation the National Pressure Ulcer Advisory Panel (NPUAP) wound staging guidelines revised earlier this year.

However, since CMS has adapted the NPUAP guidelines for OASIS purposes, the definitions do not perfectly align with each stage as described by NPUAP,” the manual states. “When discrepancies exist between the NPUAP definitions and the OASIS scoring instructions provided in the OASIS Guidance Manual and CMS Q&As, providers should rely on the CMS OASIS instructions.

It had been expected that CMS would adopt the recent wound staging guidance from the NPUAP that changed the terminology from “pressure ulcer” to “pressure injury” and added more specific language in its wound descriptions.

Tool of the MonthFeatured Scenario:

Based on the new Coding Clinic guidance, how would you code the following? A 65-year-old man comes to home health following a left knee replacement for localized traumatic arthritis. He will receive skilled nursing and physical therapy. He has had type 1 diabetes since his early 20s and has a diagnosis of PVD, both of which are stable.

Primary and Secondary Diagnoses M1025
Additional diagnoses
M1021a: Aftercare following joint replacement surgery Z47.1    
M1023b: Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.51    
M1023c: Presence of left artificial knee joint Z96.652    

 

Rationale:
The patient’s Type 1 diabetes and PVD are assumed to be connected by the ICD-10 classification and are thus coded as a diabetic manifestation, as no other cause for the PVD was given, according to Q2 2016 Coding Clinic guidance. Diabetic PVD is coded as diabetic angiopathy. No code for insulin use is required because the patient is a type 1 diabetic and insulin use is integral to the condition.

Traumatic arthritis is not coded because it was said to be localized to the knee that is now replaced, and is thus a resolved condition. Code Z96.652 is coded to capture the presence of the left artificial knee, in accordance with tabular instruction at Z47.1.

June 2016

Coding NewsNPUAP releases staging definitions that could mean hundreds of dollars for agencies

When a wound has slough or eschar, it’s not a Stage 2 wound, according to recent guidance from the National Pressure Ulcer Advisory Panel (NPUAP).

Agencies often mark a shallow Stage 3 wound with slough or eschar as a Stage 2 on OASIS responses, because the wound is not deep, says Brandi Whitemyer, RN, COS-C, HCS-D, HCS-O, a home health and hospice consultant in Canton, Ohio.

This is a costly mistake that results in a loss of clinical points and potentially $500 or so on episodes, she says. This clarification supports the knowledge never to mark an ulcer with slough or eschar of any type as Stage 2 on the OASIS but rather at least a Stage 3 if those are present in the wound bed.

This is just one of the many changes the NPUAP made April 8 and 9 to its staging definitions. The NPUAP also added the term “pressure injury” to replace “pressure ulcer” and decided Arabic numbers should be used in names of the stages instead of Roman numerals. That’s in line with changes made in OASIS-C2.

In addition, the term “suspected” has been removed from the Deep Tissue Injury diagnostic label, and the panel agreed upon additional pressure ulcer definitions including those related to Medical Device Related Pressure Injury and Mucosal Membrane Pressure Injury. CMS is still deciding whether it will adopt these definitions as official guidance to be used when clinicians answer the OASIS form.

The latest OASIS guidance in a simple online tool!
With Coding Center EXPERT, DecisionHealth provides all the official OASIS regulatory guidance with plain-English interpretation from leading experts – updated in real-time! And it's integrated into our existing ICD-10 code lookup and guidance tool. There's no better way to ensure full reimbursement and increased productivity! But don't take our word for it. See it in action on Thurs., July 14, 2016 at 1:00 PM ET


Coding TipRevised LCD makes getting frequent HbA1c tests a recommendation

Medicare Administrative Contractor (MAC) Palmetto GBA in June made another revision to a Local Coverage Determination (LCD) involving diabetic patients. Agencies now are recommended — not required — to provide frequent documentation for HbA1c tests for diabetic patients.

“Based on Palmetto GBA’s claims data and the increased risk of emergency department (ED) encounters and acute inpatient admissions related to hypoglycemia in this population, physicians and home health agencies should consider the inclusion of HbA1c testing in the home health plan of care,” Palmetto’s revised LCD states.

“For other beneficiaries with stable glycemic control (defined as two consecutive HbA1c results meeting the treatment goals specified in the plan of care), performing the HbA1c test at least two times a year may be considered,” according to the LCD.

The change, effective for services performed on or after June 3, 2016, will greatly benefit agencies, says Judy Adams, HCS-D, president of Adams Home Care Consulting in Durham, N.C.

In prior months, Palmetto, the MAC in 16 mostly southern states, began issuing denials on home health claims with a diagnosis of diabetes coded in either M1021 (Primary diagnosis) or M1023 (Other diagnoses) when there was no current HbA1c test result on file. Many doctors pushed back, saying patients don’t need these blood tests on a routine basis.

But now, while language within the LCD still encourages agencies to incorporate HbA1c results into the plan of care and is a recommended best practice, the test is no longer required to get a claim paid, Adams says.

Tool of the MonthTool of the Month

Building a solid foundation of the rules that govern the use of the ICD-10-CM codes – the official conventions and guidelines – is an imperative first step to accurate coding. The following chart lists several common coding rules, and identifies whether it’s a coding convention or a coding guideline:

Conventions Guidelines
Etiology/manifestation sequencing Look up code in the index first and verify in the tabular
Tabular instructions Mandatory multiple coding
Punctuation (brackets, parentheses, colons) Sequela or late effect sequencing
Includes & Excludes notes Code to the highest level of specificity
Meanings of “and” and “with” Avoid coding symptoms integral to a diagnosis

More than 3,000 I-10 code changes make it impossible to prepare on your own, which is why specific guidance and expert-led instruction is your only lifeline. The best time to prepare is now and your first step is to join us at this year’s Home Health Coding Summit where you’ll get four days of home health-specific instruction, networking opportunities and so much more. Space is limited so reserve your seat now!


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May 2016

Coding NewsICD-10 data suggests overuse of Z codes could impact payments

Audit your coding with a particular focus on Z codes and any specific diagnoses your agency codes with great frequency. Track your error rate by coder and diagnosis, and address those issues with specific training. Doing so will lessen the mistakes your agency makes with coding under ICD-10.

New data provided by Seattle-based OCS HomeCare, now a part of the ABILITY Network, indicate agencies could be overusing Z codes, applying them for aftercare instead of coding the underlying condition or injury.

Z47.- (Orthopedic aftercare) was the most common ICD-10 subcategory listed as a primary diagnosis – 6.6% of episodes – in the fourth quarter of 2015, OCS HomeCare data show.

Z48.- (Encounter for other postprocedural aftercare), meanwhile, was the third most common ICD-10 subcategory listed as a primary diagnosis – 5.7% of episodes – during that timeframe.

Z47.89 (Encounter for other orthopedic aftercare) and Z48.89 (Encounter for other specified surgical aftercare) specifically have been used as catch-all codes and, while they sometimes are used appropriately, they often aren’t, says Trish Twombly, HCS-D, senior director for DecisionHealth in Gaithersburg, Md.

So what should you do? Train on how to code a trauma wound with an injury code and the appropriate seventh character, Twombly suggests. Under ICD-10, coders should not use an aftercare code even after the trauma wound has been surgically repaired. If they do, they should prepare to lose rightful reimbursement. For example, agencies should assign S01.411D (Laceration without foreign body of right cheek and temporomandibular area, subsequent encounter), and not an aftercare code such as Z48.89. Injury codes such as S01.411D are eligible as Skin1 diagnoses for up to 19 case-mix points if coded as primary.

Attention Home Health Coding Center Users!
Join us Thursday, May 26 @ 2pm ET for a Tips & Tricks session where we’ll show you how to use the application to quickly pinpoint the appropriate wound or burn code, so you can avoid auditor scrutiny and receive the reimbursement you deserve.


Coding TipExpect hospice payments to rise by $330 million

Medicare’s hospice payments, adjusted for inflation and other factors, would rise an estimated 2% in 2017, according to the proposed hospice payment rule posted April 21. The $330 million increase is the result, among other things, of a market basket update reduced by a productivity adjustment and a point adjustment set by the Affordable Care Act.

By comparison, the 2016 final rule included a 1.1% increase – $160 million – in Medicare’s hospice payments.

Under the 2017 rule, hospices in rural and urban areas would experience an average increase of 2% and 1.9%, respectively. Hospices in the urban Pacific and rural Pacific regions would experience the largest increases — 2.6% and 2.7% — while hospices in the West North Central region only would experience a 1% increase.

For routine home care, the payment rate for days one through 60 would be $190.41 in 2017, compared to $186.84 in 2016.

For days 61 and beyond, payments would be $149.68 in 2017, compared to $146.83 in 2016.

Tool of the MonthFeatured Quiz

  1. Which of the following is acceptable as the principal diagnosis on a hospice claim?
    1. F02.80 (Dementia in other diseases classified elsewhere without behavioral disturbance)
    2. R62.7 (Adult failure to thrive)
    3. Z48.812 (Encounter for surgical aftercare following surgery on the circulatory system)
    4. None of the above


Fact: Increased scrutiny has put your hospice’s revenue at risk, and only correct coding will keep your claims compliant and auditors at bay.

Empower your hospice agency to submit clean claims for fast and full reimbursement using the Coding Center! Join us May 18th @ 1:00 p.m. EDT for a FREE, hospice exclusive demo to see it in action.


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April 2016

Coding NewsCoding Basics: Correctly code arterial ulcers in ICD-10

The key to coding arterial ulcers in ICD-10 is to first identify the underlying cause of the ulcer. Disease processes that can cause arterial ulcers include peripheral artery disease, atherosclerosis and diabetes.

Then, select the appropriate L97.- code to identify the ulcer’s location (such as calf, ankle, etc.), laterality (right or left side or bilateral) and severity. You’ll need to know whether the wound:

  • Is limited to the breakdown of the skin
  • Has exposed the fatty (or subcutaneous) layer of tissue
  • Has caused necrosis of muscle (this is associated with a break in, or loss of, muscle surface fiber membrane, which results in irreversible damage to the whole, or a segment of, the muscle fiber)
  • Has caused necrosis of bone (this is death of the bone from ischemia, infection or malignancy)
  • Has unspecified severity (avoid using this code for its lack of specification)

Tip: The severity of the ulcer may be determined and coded based upon nursing documentation, but confirmation of necrosis of bone should be obtained by diagnostic testing such as MRI; it cannot be determined through visualization alone.

Coding TipPrepare for thousands of ICD-10 code changes

The Centers for Disease Control and Prevention (CDC) has proposed 2,670 ICD-10-CM code changes that would take effect Oct. 1, 2016. This is the first update since the nation transitioned to the new code set after a five-year code freeze. The finalized code changes will be posted to the CDC’s website in June.

Specifically, there are 1,943 new, 422 revised and 305 deleted codes. Some of the most notable additions are:

  • 260 new diabetes combination codes for reporting manifestations
  • 152 new codes added to the musculoskeletal chapter including bunions, temporomandibular joint conditions (adhesions, arthralgia), cervical spine disorders and atypical femoral fractures
  • 885 new codes in Chapter 19, the majority of which are fracture codes including neck, base of skull, facial bones, Salter-Harris calcaneal fractures as well as other physeal fractures

Tool of the MonthScenario: Diabetic arterial ulcer, CAD

An 80-year-old female is admitted to home health for wound care to an ulcer on left ankle that was caused by diabetic angiopathy. Muscle destruction is evident when changing the dressing. She also has CAD and is dependent on insulin.

Code the scenario in ICD-10:

Primary and Secondary Diagnoses M1025
Additional diagnoses
M1021a: Type 2 diabetes mellitus with other skin ulcer E11.622    
M1023b: Non-pressure chronic ulcer of left ankle with necrosis of muscle L97.323    
M1023c: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.51    
M1023d: Atherosclerotic heart disease of native coronary artery without angina pectoris I25.10    
M1023e: Long term (current) use of insulin Z79.4    
  • Because the focus of care is the ulcer caused by diabetic angiopathy, the combination code for diabetes with skin ulcer is assigned in M1021. A diabetic ulcer to the ankle is not included in E11.621, Type 2 diabetes mellitus with foot ulcer, so E11.622 must be assigned to indicate other ulcer.
  • Follow E11.622 with code L97.323 for the ulcer location, laterality and severity. There is evidence of muscle destruction; therefore, the ulcer can be coded as having caused necrosis of muscle.
  • The combination code for diabetes that has caused arterial disease also is assigned as a secondary diagnosis.
  • The patient’s CAD is not the cause of the ulcer, but it is a relevant comorbidity and has the potential to complicate the healing of her diabetic arterial ulcer Therefore, it’s coded as well.
  • The patient is a type 2 diabetic who is dependent on insulin. Therefore, the code for insulin use must be assigned.

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March 2016

Coding TipAgencies using GEMs to code breast cancer could lose $40 per episode

Agencies relying solely upon the general equivalency mappings (GEMs) to code in ICD-10 could be costing themselves a lot of money.

For example, the GEMs map ICD-9 breast cancer code 174.9 (Malignant neoplasm of breast (female), unspecified) to the non-specific C50.919 (Malignant neoplasm of unspecified site of unspecified female breast) – a diagnosis that doesn’t carry case-mix points. However, CMS assigned case mix to more specific codes in the same category that identify which breast – C50.911 (Malignant neoplasm of unspecified site of right female breast) and C50.912 (Malignant neoplasm of unspecified site of left female breast). Assigning these more appropriate codes means your agency could receive $39.61 more in reimbursement per episode, according to Seattle-based National Research Corporation.

The data in the table below are based on 6,378 standard episodes in 2014 that had ICD-9 code 174.9 as a primary, other or payment diagnosis:

Mapped to breast cancer code (C50.919), no points received Mapped to breast cancer codes (C50.911, C50.912) points received Difference
Case weight per episode 0.9514 0.9655 0.0141
Reimbursement per episode $2,799.15 $2,838.76 $39.61
Source: National Research Corporation, Seattle

 

Attention Home Health Coding Center Users! Join us Tuesday, March 29 @ 2pm ET for a Tips & Tricks session where we’ll show you how to use the application to quickly pinpoint the appropriate cancer diagnosis code, including how to use our I-10 Mapping Wizard to go beyond the GEMs.

Coding NewsMAC alerts agencies to major RTP reasons

A lack of proper coder training and confusion about what to do with patients who had care spanning Oct. 1, 2015, are among the main reasons home health agencies and hospices have had claims returned to provider (RTP’d) since ICD-10’s implementation, according to Medicare Administrative Contractor (MAC) CGS. Among the ICD-10-related errors CGS has identified since Oct. 1:

  • Claims submitted with invalid ICD-10 codes
  • Unspecified diagnosis codes listed as primary diagnoses
  • Transactions contained both ICD-9 and ICD-10 codes

In addition to the errors CGS identified, experts say many agencies have had claims RTP’d because improperly trained coders have been leaving off the 7th character or not using the placeholder “x” when the code being assigned requires a seventh character but is less than six characters.

Tool of the MonthFeatured Quiz

  1. Your patient is a 68-year-old female. What is the proper code for a primary malignant neoplasm of the left nipple?
    1. C50.012
    2. C50.022
    3. C79.81
    4. D24.2

Answer: A.

February 2016

Coding TipCombination codes simplify sepsis coding

Assign just one combination code, A40.9 (Streptococcal sepsis), to capture sepsis caused by a streptococcal organism in ICD-10. That’s a change from ICD-9 where you had to code 038.0 (Streptococcal septicemia) for the infecting organism first, then 995.91 (Sepsis) to indicate that it caused sepsis.

The availability of combination codes that capture both the infecting organism and the resulting systemic inflammation that characterize sepsis has helped to simplify the coding of sepsis conditions in ICD-10.

But choosing the right sepsis code(s) and sequencing them correctly is still a confusing task for even the most seasoned coders. And distinguishing among the plethora of terms used to describe the condition can be particularly troublesome.

Attention Home Health Coding Center Users! Join us Monday, February 29 @ 2pm ET for a Tips & Tricks session where we'll show you how to use the application to quickly find the correct infection codes, including sepsis.

Tips to get sepsis coding right

Here are four tips to ensure your sepsis coding is correct:

  • Don’t think you can’t code sepsis in home health. Patients frequently come to home health still in active treatment for sepsis conditions. Furthermore, patients with sepsis conditions require a lot of care and if you code a less serious condition, the claim may not support the necessary level of nursing utilization.
  • Use the presence of IV antibiotics as a clue that a patient may still have active sepsis and confirm with the physician. Remember, only the physician can confirm a diagnosis of sepsis or that the sepsis is still an active condition.
  • Do not assume that a patient’s organ failure is related to his sepsis simply because both diagnoses are on the chart. Physician documentation must establish the connection.
  • Query the physician for more detail if you see a diagnosis of urosepsis. Urosepsis is a non-specific term that is not synonymous with sepsis and has no default code, according to ICD-10 official coding guidelines.

Coding NewsOASIS-C2 draft released with new items

CMS has released a draft version of its OASIS-C2 data item set for home health, scheduled for implementation Jan. 1, 2017.

The new OASIS item set, released Dec. 22, 2015, was created to comply with the requirements for standardized, cross-setting measures for post-acute care under the IMPACT Act, the federal agency said in a news release.

The draft includes the following major changes:

Three new standardized items — M1028 (Active diagnoses, comorbidities and co-existing conditions), M1060 (Height and weight) and GC0170c (Functional abilities and goals at SOC/ROC).

Modification to, and renumbering of, select medication and integumentary items to standardize with other post-acute settings of care: M1311 (Current number of unhealed pressure ulcers at each stage), M1313 (Worsening in pressure ulcer status since SOC/ROC), M2001 (Drug regimen review), M2003 (Medication follow-up) and M2005 (Medication intervention).

The look-back period and item number was changed in five items:

Current M Item in OASIS-C1 Item Description Proposed M Item in OASIS-C2
M1500 Symptoms in heart failure patients M1501
M1510 Heart failure follow-up M1511
M2015 Patient/caregiver drug education intervention M2016
M2300 Emergent care M2301
M2400 Intervention synopsis M2401

 

Formatting changes were made — where responses are mutually exclusive — throughout the item set to convert multiple checkboxes to a single box for data entry and to change the numbering for pressure ulcer staging from Roman to Arabic numerals.

Editor’s note: To view the draft, go to https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/OASIS-Data-Sets.html and to see the data specifications, go to https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/OASIS/DataSpecifications.html.

Tool of the MonthScenario: MRSA sepsis

A 72-year-old man is admitted to home health to continue treatment with a primary diagnosis of MRSA sepsis. He will receive IV antibiotic therapy until the infection completely resolves.
 

Code the scenario in ICD-10:

Primary and Secondary Diagnoses M1025
Additional diagnoses
M1021: Sepsis due to Methicillin resistant Staphylococcus aureus A41.02    
M1023: Encounter for adjustment and management of vascular access device Z45.2    
M1023: Long term (current) use of antibiotics Z79.2    


Rationale:
Only one code is required to capture the MRSA sepsis in ICD-10 because it includes the sepsis as part of the combination code (A41.02).

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