Home Care Matters Monthly

Be certain when choosing codes for Alzheimer’s disease

Accurate coding for Alzheimer’s disease is extremely important as it is a frequent diagnosis in home health and may be a primary reason for admission or even complicate care.

To correctly code for Alzheimer’s disease, you must first understand that the term dementia is a general term which describes a continuous decline in thinking, behavioral and social skills and disrupts a person’s ability to function independently.

There are four codes available to assign to Alzheimer’s disease. To code, first begin in the Alphabetical Index with terms “Disease, Alzheimer’s” and note that the default code is G30.9 (Alzheimer’s disease, unspecified).

The italicized brackets next to the code in the Alphabetic Index indicate that it is part of an etiology/manifestation combination, so two codes are necessary in order to code each type of Alzheimer’s disease correctly.

The second code refers to the absence or presence of any behavioral disturbance that the patient exhibits, and further serves to describe the patient’s status. These are captured through codes F02.80 (Dementia in other diseases classified elsewhere without behavioral disturbance) and F02.81 (Dementia in other diseases classified elsewhere with behavioral disturbance).

The manifestation codes for Dementia in diseases classified elsewhere are found in Chapter 5, (Mental, Behavioral, and Neurodevelopmental Disorders) under the category “Dementia in other diseases classified elsewhere.”

All Alzheimer’s disease codes are valid primary diagnosis codes under the Patient-Driven Groupings Model (PDGM), although no comorbidity points are assigned. When coded as a primary diagnosis, it’s important to remember that interventions addressing Alzheimer’s disease and any manifestations should be included in the plan of care.

Tip: An Excludes 1 note in the tabular index instructs us that when coding Alzheimer’s we cannot also code senile brain degeneration or the more general terms, senile dementia or senility.

CMS’ January release of quarterly OASIS Q&As offer guidance on PDGM, function items

When responding to M0104 (Date of referral) clinicians should enter the date the agency received a valid referral, and must keep in mind that a primary diagnosis eligible for reimbursement under the Patient-Driven Groupings Model (PDGM) is not necessarily required for a referral to be considered valid.

This is just one piece of guidance included in CMS’ January of OASIS quarterly Q&As published to the CMS website Jan. 21. The latest release of OASIS Q&As delves into issues around PDGM as well as M-items capturing activities of daily living (ADLs) and GG items capturing mobility and self-care.

In the response to Question 3, CMS explains a referral is valid when the agency receives adequate information about the patient including name, address, contact information, diagnosis and/or general home care needs and ensures the referring physician or another physician will provide the plan of care and ongoing orders.

In the scenario outlined in Question 3, the agency receives a complete referral from a physician at an inpatient facility on Jan. 1, 2020, and the patient is discharged to home health that day. The diagnosis provided on the referral doesn’t fall into a PDGM clinical grouping, so intake staff call to get a more specific diagnosis. The agency gets the more specific diagnosis on Jan. 4, 2020 and starts care on Jan. 5, 2020. CMS explains that the agency received adequate information including a relevant diagnosis and had a valid referral on Jan. 1, 2020, so that would be the correct admission date to enter on M0104.

“The assessment process, along with collaboration with the physician, may lead to identification of additional diagnoses for care planning and/or reimbursement purposes,” CMS explains in the response.

Delays in getting care started immediately after receiving and accepting a referral could result in timely initiation of care issues, lapses in patient care, loss of referrals and CMS scrutiny, notes Arlynn Hansell, PT, HCS-D, HCS-H, HCS-O, COS-C, owner of Therapy and More, LLC in Cincinnati.

“You’ve got to get it clarified but get your clinician out there and get that patient started,” Hansell says. “We have a valid referral we just need to get a diagnosis that will play nice in the sand box.”

Absence of a diagnosis code that qualifies for payment doesn’t mean that patient doesn’t need care, Hansell adds.

“We just need a valid diagnosis, so that’s our problem not the patient’s,” Hansell says.

Scenario: Diabetes, emphysema and Alzheimer’s disease management

A 69-year-old woman was admitted to the hospital with delirium. Her diagnoses include insulin dependent diabetes and emphysema. She was found wandering in her yard at night wearing her nightgown, and her family reported that she has been forgetting to administer her insulin lately, acting unusually and had lost herself several times while driving in the past few months. She was successfully treated for a UTI but the delirium did not resolve. A geriatric psych workup revealed a diagnosis of rapidly progressing Alzheimer’s disease with associated behaviors. She is having episodes of sundowning at home and SN is addressing her family’s need to learn to manage her Alzheimer’s disease symptoms and diabetes.

Code the scenario:

Additional diagnoses: Z79.4 (Long term (current) use of insulin), Z87.440 (Personal history of urinary (tract) infections).

Rationale:

• The focus is on the family learning to care for the patient’s rapidly progressing Alzheimer’s, therefore you would first code G30.9 (Alzheimer’s disease, unspecified).
• The provider has identified behaviors, including wandering, so you would follow that code with F02.81 (Dementia in other diseases classified elsewhere with behavioral disturbance).
• Delirium episodes are continuing and would be captured with F05 (Delirium due to known physiological condition).
• The comorbid diagnosis of diabetes with insulin administration is a focus of concern for the family. This would be coded through assigning E11.9 (Type 2 diabetes mellitus without complications)
• The patient’s emphysema would be captured through coding J43.9 (Emphysema, unspecified).
• The documentation states the patient has been found wandering. This would need to be coded through assigning Z91.83 (Wandering in diseases classified elsewhere). Note: Per a “Code first” note listed under Z91.83, you must first assign the Alzheimer’s code before assigning this code.
• Additional diagnosis codes Z79.4 (Long term (current) use of insulin) and Z87.440 (Personal history of urinary (tract) infections) would be assigned in this scenario.

Failure should not be an option when coding heart failure

Be sure you have all necessary and accurate documentation when coding for heart failure — or risk errors.

Heart failure is a chronic condition frequently encountered in patients receiving home health services. Additionally, there is more than one type of heart failure, therefore it is very important to know how code each type correctly and when to query for further needed information.

Heart failure’s inclusion in the Patient-Driven Groupings Model (PDGM) clinical grouping MMTA — cardiac/circulatory and both low and high comorbidity adjustments under Heart 11 underscore the importance of accurately capturing this condition.

When assigning heart failure, always begin in the alphabetic index under Failure, heart then search sub-terms for type, etiology or other key words documented. Utilizing the index, sub-terms and tabular instructions are the keys to fully capturing all aspects of heart failure.

Heart failure can be documented using several different terms. Understanding this language is required for accurate ICD-10 code assignment.

There are multiple types of heart failure that may occur at the same time. These conditions may require more than one code, a combination code or both.

A patient may have a diagnosis of acute systolic heart failure as well as chronic diastolic heart failure. This would require two codes — I50.21 (Acute systolic (congestive) heart failure) and I50.32 (Chronic diastolic (congestive) heart failure).

In certain circumstances, one combination code may capture two conditions. An example is when both systolic and diastolic heart failure or combined systolic and diastolic heart failure is documented.

Agencies struggle with timely OASIS, improving speed to avoid claim rejections

Agencies need to focus on submitting the OASIS on time to avoid denials or claims getting returned to provider (RTP), resulting in potentially costly delays.

Timely submission is even more important in a Patient-Driven Groupings Model (PDGM) world, because billing must be completed faster. Any delays in payment could further impact cash flow during the transition to the new payment model.

The lack of a corresponding OASIS assessment was one of the most common claim submission errors in home health in November, according to Medicare Administrative Contractor (MAC) CGS. Claims are returned to provider for reason code 37253 when this happens.

Similarly, one of the top five reasons a home health claim was denied by MAC Palmetto GBA between April and June was because the MAC was unable to determine medical necessity of the HIPPS code billed because an appropriate OASIS wasn’t submitted. This situation results in denial code 5FNOA.

To be considered timely, agencies must ensure the OASIS assessment has completed processing and was successfully accepted into the Internet Quality Improvement and Evaluation System (iQIES).

A final claim will be denied if both of the following conditions exist: The OASIS assessment is not in iQIES and it has been more than 30 days since the assessment was completed. For an undetermined amount of time, CMS is allowing a little extra leeway, extending the deadline to 40 days, according to the change request.

If, however, a claim is submitted without a corresponding OASIS, but it has been less than 30 days, the claim will RTP.

Scenario: Acute on chronic systolic CHF

A patient is admitted to home care following an inpatient stay for acute on chronic systolic congestive heart failure. The cardiologist further documents biventricular heart failure and end-stage heart failure.

Code the scenario:

Rationale:

• A search in the alpha index under the main term Failure, heart and sub-terms systolic, acute and chronic direct the coder to the combination code I50.23 (Acute on chronic systolic (congestive) heart failure).
• Additional searches under the sub-terms biventricular and end-stage heart failure direct the coder to I50.82 (Biventricular heart failure) and I50.84 (End stage heart failure) respectively. Note the instructional under I50.82 to “code also” the type of left ventricular failure as systolic, diastolic, or combined, if known and the “code also” note under I50.84 to the type of heart failure as systolic, diastolic, or combined, if known. A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter (ICD-10-CM Official Guidelines for Coding and Reporting I.17).

Coding for infections doesn’t have to be a struggle

Coding an infection in home health can be challenging, but there are simple strategies that can help cut through the confusion.

For example, use a code for late effects of infectious conditions (B90-B94) when the active disease is no longer present, but the patient has a residual effect from the condition or disease.

These codes are located in Chapter 1 (Certain Infections and Parasitic Disease). This chapter may be divided in two parts. The first, A00-B94, includes infectious conditions related to specific locations or conditions.

Categories in this part often used in home health are intestinal infections such as Escherichia coli (A04.0-A04.4) and other bacterial disease such as sepsis (A40-A41). Viral hepatitis (B15-B19) and Human immunodeficiency virus [HIV] (B20) are also located here.

Categories B95-B97 encompass the second part of Chapter 1. Located here are codes for specific organisms used in addition to a condition code, such as a urinary tract infection.

When coding infections, accuracy begins with a search for the condition in the alphabetical index.

For example, enteritis with clostridium difficile begins with a search of the term enteritis. The coder would then look for the sub-term that specifies the organism. In this example, clostridium difficile is located under sub-term infections, due to which directs the coder to A04.71 for recurrent or A04.72 for not specified as recurrent.

When the condition does not list a sub-term for the infectious organism, the condition is often classified in chapters other than Chapter 1. In these instances, an additional code from categories B95-B97 of Chapter 1 is used to identify the specific organism.

CMS finalizes raft of OASIS changes, draft OASIS-E expected in early 2020

Big changes are coming to the OASIS in 2021, and CMS expects a draft of the revised assessment in early 2020, according to the 2020 PPS final rule.

CMS released an OASIS-D to OASIS-E crosswalk with its 2020 PPS proposed rule, indicating the revised assessment already has its name.

The revised assessment will add 27 new items — or standardized patient assessment data elements (SPADEs) — at various timepoints, according to the final rule and corresponding supplemental documents.

“I think that’s what we’re going to be talking about a lot next year,” says Diane Link, president of Link Healthcare Advantage in Littlestown, Pa. “We need to get ready for the next big thing, and that’s SPADEs.”

The new items will capture information on cognitive function and mental status; special services, treatments and interventions; medical condition and comorbidities; impairments; and social determinants of health. The changes are designed to comply with the IMPACT Act, which calls for standardization across four post-acute settings including home health.

New cognitive items are expected to be the most challenging, adding at least 10 minutes to the admission assessment, Link predicts.

The changes come hard on the heels of recent OASIS changes as well as a new payment model. OASIS-D took effect Jan. 1, 2019, OASIS-D1 took effect on Jan. 1, 2020, along with the Patient-Driven Groupings Model (PDGM).

Implementing OASIS-E on Jan. 1, 2021, doesn’t leave much time to acclimate to these substantial changes.

Scenario: Rectal abscess, Staphylococcus aureus

A patient is admitted to home health with a diagnosis of rectal abscess. Physician documentation indicates the infectious agent as Methicillin susceptible Staphylococcus aureus. The patient also complains of pain related to postherpetic neuralgia from a recent shingles outbreak. There are no vesicle eruptions or inflammation present in the outbreak area.

Code the scenario:

Rationale:

• A search of the condition abscess, rectum directs the coder outside of Chapter 1: Certain infectious and parasitic disease to K61.1 (Rectal abscess).
• Although no “Use additional code to identify” instruction is under K61.1, an additional infectious agent code is added to fully capture the patient’s diagnosis. This aligns with ICD-10-CM guidelines for Section I.C.1.b: Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the infection code. In these instances, it is necessary to use an additional code from Chapter 1 to identify the organism.
• Postherpetic neuralgia is captured by searching neuralgia with the sub-term postherpetic. Without further specification, B02.29 (Other postherpetic nervous system involvement) is the appropriate code. The condition as well as the causative agent are both included in B02.29.

Avoid errors when coding for adverse effects, poisoning

When coding adverse effects, be sure to assign the appropriate code for the nature of the adverse effect before the adverse effect of the drug itself.

Adverse effects, poisonings, underdosing and toxic effects can happen for a variety of reasons and it’s important to understand the nuances and definitions in order to assign the most appropriate code for the situation.

When coding an adverse effect, poisoning, underdosing or toxic effect of a substance, begin your search in the Table of Drugs and Chemicals, by drug. However, be careful not to code directly from the Table of Drugs and Chemicals. Always refer back to the tabular list to confirm the correct code. It is important to know the definition of each term in order to code accurately.

The codes for adverse effects, poisoning, underdosing and toxic effects can be found in Chapter 19 (Injury, Poisoning and Certain Other Consequences of External Causes). This is the largest chapter in the ICD-10-CM manual, therefore, it is important to know how to navigate this chapter to accurately code each scenario.

The codes for an adverse effect are found in categories T36 to T50 and have a fifth or sixth character of 5.

An adverse effect is defined as “a reaction to a drug that has been correctly prescribed and properly administered,” per coding guidelines.

Chapter-specific coding guidelines instruct the coder to “assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50).” [1.C.19.e.5.a]

For example, if a patient had an adverse effect of bradycardia after taking Digoxin, we would code the bradycardia first, as it is the nature of the adverse effect.

We would follow this with the T46.0x5D (Adverse effect of cardiac-stimulant glycosides and drugs of similar action, subsequent encounter) code to identify the drug causing the adverse effect.

Quarterly OASIS Q&A offers insight into what codes to include on M1021, M1023

The latest release of CMS’s quarterly OASIS Q&As delves into issues around the Patient-Driven Groupings Model (PDGM) and OASIS-D1, providing much-needed guidance for agencies on how to meet CMS expectations for the assessment heading into 2020.

Among the most noteworthy guidance updates are several Q&As providing direction on which codes should be included on M1021 (Primary diagnosis) and M1023 (Other diagnoses).

The guidance comes as a welcome, if not complete, clarification of an ongoing point of confusion for coders.

Prior to the release, agencies had expressed some confusion over whether they should follow guidance found within the official coding guidelines and the OASIS guidance manual or guidance found within the revised Home Health Conditions of Participation (CoPs).

Coding guidelines instruct to report diagnoses that affect the plan of care. The interpretive guidelines, however, state that the individualized plan of care must include all pertinent diagnoses, further explaining that this means “all known diagnoses.”

The October 2019 quarterly OASIS Q&As — published to the CMS website Oct. 15 — is the first time CMS has directly addressed the question of which guidance to follow.

Questions 20 and 21 ask for clarification around whether M1021 and M1023 should include all known diagnoses, or only current diagnoses.

Question 20 asks CMS to “specifically clarify if M1021 and M1023 should include known diagnoses that are resolved or diagnoses that do not have the potential to impact the skilled services ordered.”

In the response, CMS explains OASIS guidance states agencies should include “only current diagnoses actively addressed in the [plan of care] or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis even if not the focus of any home health treatment itself.”

CMS goes on to say that the items should exclude any resolved diagnoses or diagnoses that don’t have the potential to impact skilled services the agency provides. This is consistent with coding guidelines.

Question 21 notes that under the Patient-Driven Groupings Model (PDGM), diagnosis grouping will be based on the claim, not the OASIS. The question goes on to ask what kinds of diagnoses can be listed on the claim.

“Any additional diagnosis listed on the claim should follow the OASIS definitions for primary and secondary diagnosis found in the OASIS Guidance Manual. Include only current diagnoses actively addressed in the plan of care or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis even if not the focus of any home health treatment itself,” CMS sates in the response to Question 21.

CMS reiterates that any resolved diagnoses or diagnoses that do not have potential to impact skilled services provided by the agency should be excluded from both the OASIS and the claim, “even if they are known/documented diagnoses.”

Scenario: Adverse reaction to IV antibiotic

A 78-year-old female patient is referred to home health after a hospital stay due to cellulitis of the right foot. The patient developed generalized dermatitis as an adverse reaction to the IV antibiotic Amoxicillin used for the initial treatment while inpatient. Skilled nursing will focus on assessing the cellulitis area and the patient’s response to a new oral antibiotic at home as well as caring for and assessing the contact dermatitis.

Rationale:

• The cellulitis is the focus of care; therefore, it is coded as primary.
• When coding an adverse effect, the nature of the adverse effect is sequenced first; in this case the generalized dermatitis.
• The T code specifying the substance causing the adverse effect is coded as an additional code with the 6th character of five to indicate an adverse effect and the 7th character “D” to indicate subsequent care for the healing and recovery phase.

It’s crucial to make the right connections when coding joint replacements

To code joint replacements, think about connecting an existing condition with its treatment and/or status. Code selection and pairing can be straightened out by remembering two things: We need to know what’s done and where.

Joint replacements can occur for a variety of reasons, most commonly for osteoarthritis of the joint. It can be primary (caused by general wear and tear of the joint) or secondary (caused by infection or inflammation after a previous traumatic injury to the joint) or for joint damage caused by other conditions such as rheumatoid arthritis.

Uncomplicated joint replacement coding requires two codes — both Z codes, found in Chapter 21 — Factors Influencing Health Status.

Code Z47.1 (Aftercare following joint replacement surgery) identifies the care that will be provided. A code from the Z96.6- subcategory (Presence of orthopedic joint implants) identifies the joint that has been replaced. The last two characters specify the joint (1 is shoulder, 2 is elbow, 3 is wrist, 4 is hip, 5 is knee, 6 is ankle, 9 is finger) and laterality (1 is right, 2 is left).

Since the joint condition that necessitated the replacement is resolved, do not code it.

When multiple joint replacements are present, each replaced joint is coded separately. That’s the case except for a few unique situations that identify the presence of bilateral joints of the same type.

OASIS-D assessments taking significantly longer, focus on GG0170 to improve speed

Clinicians are taking more time to complete OASIS-D than they were to complete OASIS-C2, in part because of a new multi-part item capturing mobility.

Agencies should take steps to help clinicians improve efficiency when assessing GG0170 (Mobility) to mitigate the productivity drain associated with the revised assessment.

About 53% of agencies say start of care (SOC) assessments take 11 to 30 minutes longer under OASIS-D, according to the 124 respondents to a question on DecisionHealth’s 2019 Home Health Clinician Productivity Survey.

And about 51% of survey respondents say GG0170 is the item that takes the most time. Industry experts aren’t surprised.

One challenge is that many agencies are not fully embracing the expanded one-clinician rule, says Arlynn Hansell, owner of Therapy and More, LLC in Cincinnati. While one clinician still is responsible for completing the OASIS, the expanded rule encourages clinicians to collaborate with the patient, caregivers and other health care personnel on all OASIS data items within the comprehensive assessment.

GG0170 and GG0130 (Self-care) aren’t going anywhere, though, so clinicians must improve on these items, Hansell says.

Aim to assess an activity just once, but score it twice. After assessing for the activity, the clinician can respond to both GG and M-items. One example is GG0170D (Mobility, Sit to stand), GG0170E (Mobility, Chair/bed-to-chair transfer) and M1850 (Transferring) to assess sit to stand and bed-to-chair transfer.

Scenario: Traumatic arthritis and knee replacement

A 46-year-old patient is admitted to home health following a planned joint replacement for traumatic arthritis of the left knee caused by a skiing accident several years ago. He also has hypertension and hyperlipidemia.

Rationale:

• The aftercare for the planned joint replacement would be captured through Z47.1 (Aftercare following joint replacement surgery).
• You would also need to code Z96.652 (Presence of left artificial knee joint).
• The patient’s hypertension would be captured through I10 (Essential (primary) hypertension) and his hyperlipidemia would be captured through E78.5 (Hyperlipidemia, unspecified).

Keep your sanity when coding mental conditions

Code a psychiatric condition if a patient’s been diagnosed with one, whether or not it’s the focus of any specific home health intervention.

This is because mental conditions are important comorbidities that will impact a patient’s care and thus should be reported, says Trish Twombly, HCS-D, an independent home health consultant and coding expert based in Dallas.

And considering that, according to the Centers for Disease Control and Prevention (CDC), roughly one in five adults (about 20 percent) age 55 years and older are affected by some kind of mental health concern, these are diagnoses you’re likely to encounter with some regularity.

Anxiety and mood disorders like depression and bipolar disorder are among the most common mental disorders in older adults, according to the CDC.

Depression in particular can have a significant impact on older adults, leading to physical, mental and social impairments and adverse effects on the course and complications of chronic disease, according to the CDC.

Depression in the home health population is “a very important comorbidity,” Twombly concurs.

Under the Patient-Driven Groupings Model (PDGM), which takes effect on or after Jan. 1, 2020, certain codes such as F32.9 (Major depressive disorder, single episode, unspecified) will be factored into comorbidity adjustments when they interact with certain diagnoses.

Comorbidity adjustments yield increased payments when a specific combination of diagnosis categories exist for a patient. [See Table 10 and Table 11 in the 2020 proposed PPS rule for home health for additional details.]

Since M1800 increased in importance, it’s even more vital to train staff on it

Ensure clinicians fully understand how to fill out the OASIS item involving grooming.

Beginning this year, the item is part of value-based purchasing. And grooming will take on even more importance in 2020 under the Patient-Driven Groupings Model (PDGM).

In addition, CMS considers a significant decline in three or more activities of daily living (ADLs), such as grooming, to be a potentially avoidable event. CMS previously instructed surveyors to pay close attention to patients who experience potentially avoidable events.

M1800 (Grooming) is clearly becoming more important, “and I think agencies are going to spend a little more time explaining this item to people,” says Jennifer Sandel, co-owner of Home Care Service Solutions LLC in Battle Creek, Mich.

In addition to the six items that currently determine functional case-mix adjustment, CMS added M1800 and M1033 (Risk for hospitalization) to determine the patients’ functional impairment levels under PDGM.

A home health period of care will receive points based on responses associated with each of those eight functional items.

“The sum of all of these points results in a functional score, which is used to group home health periods into a functional level with similar resource use,” CMS says in the 2019 PPS final rule.

There are three functional levels — low, medium and high — with about one third of home health periods coming from each of the clinical groups within each functional impairment level.

In order to calculate the case-mix adjusted payment amount for PDGM, CMS decided to add collection of M1800 and M1033 at follow-up. Those OASIS changes are effective Jan. 1, 2020.

Scenario: Metastatic ovarian cancer, depression, anxiety

A 71-year-old woman recently had a colostomy placed due to metastatic cancer on her colon that spread from its primary site on her left ovary. She is admitted to home health for teaching on the care of the colostomy and for management of symptoms related to metastatic cancer. She also has diagnoses of depression and anxiety.

Rationale:

• Care and teaching on the colostomy are the focuses of care, making it necessary to code Z43.3 in the primary position. The status code for a colostomy (Z93.3) is not assigned because the agency is providing active care and teaching to the colostomy.
• The patient’s left ovarian cancer has spread to her colon. The ovarian cancer is the primary site and the colon is where the primary cancer spread, making it the secondary site. The codes are assigned accordingly.
• Both depression and anxiety are diagnosed but aren’t specifically linked. Thus, both are coded separately.
• The anxiety and depression are both important comorbidities and are thus coded as secondary diagnoses that will impact her care.

Don’t faint over the coding of blood disorders

First code K92.0 (Hematemesis), then D68.32 (Hemorrhagic disorder due to extrinsic circulating anticoagulants) followed finally by a code from T45.515- (Adverse effect of anticoagulants) for a patient who’s vomiting blood due to an adverse effect of anticoagulants.

Coding Clinic guidance from Q1 2016 specifies that a minimum of three codes are required for a patient experiencing bleeding like hematemesis (vomiting up blood), hemoptysis (coughing up blood), hematuria (blood in urine) or hematochezia (blood in stool) due to anticoagulant use.

While the Coding Clinic guidance says that either condition — K92.0 or D68.32 — could be assigned first, depending on the focus of the admission, coding guidelines require both codes to be assigned before the adverse effect code. [I.C.19.e.5.a] Note that coding experts recommend coding the bleed (K code) before the D code.

Anticoagulants are commonly prescribed medications in the home health population and are used to treat a variety of conditions including deep vein thrombosis and atrial fibrillation. They’re also often used prophylactically following joint replacement surgery.

Code D68.32 is found in Chapter 3 (Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism), which offers codes ranging from D50 (Iron deficiency anemia) to D89 (Other disorders involving the immune mechanism, not elsewhere classified).

OASIS quarterly Q&As offer guidance on appropriate skin assessment collaboration

When responding to pressure ulcer items on the OASIS, clinicians can collaborate when only a partial skin assessment is completed on the first visit, according to the most recent release of CMS quarterly OASIS Q&As.

The new guidance, published to CMS’ website July 16, offers further clarification around an issue that has been causing confusion for many clinicians in the home health industry.

Question 7 of the July 2019 Q&A release asks about what to do if a patient allows a partial skin assessment on day one, then lets a second nurse complete the remaining skin assessment on day four and a pressure ulcer is found.

In the response, CMS says that, because “a full skin assessment was not completed on the first visit, the original assessing clinician may collaborate with the second nurse (who is completing the first clinical skin assessment) regarding the presence/status of any pressure ulcers.”

“It definitely appears like they’re relaxing things a little bit, because there has been a lot of pushback from the industry,” says Arlynn Hansell, PT, HCS-D, HCS-H, HCS-O, COS-C and owner of Therapy and More, LLC in Cincinnati.

Responses to M1311 and other pressure ulcer items still must be based on the first skin assessment. But if only a partial assessment can be done in the initial assessment, collaboration is permitted with the remaining skin assessment.

Scenario: Acute-on-chronic atrial fibrillation, blood in urine

A 69-year-old woman is admitted to home health with an acute exacerbation of chronic systolic heart failure. She also has a diagnosis of chronic atrial fibrillation, which is treated with long-term anticoagulant medication. She recently began experiencing blood in her urine, which her physician diagnosed as a side effect of her anticoagulant. Her medication was adjusted but she continues to take anticoagulants.

Rationale:

• As the focus of care, the acutely exacerbated chronic systolic heart failure is coded in the primary position.
• The patient’s blood in urine is documented as an adverse effect of the patient’s use of anticoagulant medication. Thus, it is captured first with R31.9, then with D68.32 followed by the code for the adverse effect, in accordance with Coding Clinic guidance.
• The patient continues to be treated for chronic atrial fibrillation with anticoagulants. Thus, I48.2 and Z79.01 are also assigned.

A periprosthetic fracture needs more than one code

Make sure to assign a code from the M97.- category (Pv eriprosthetic fracture around internal prosthetic joint), along with the code for the specific broken bone, for a patient with a periprosthetic fracture. Otherwise you will have coded the diagnosis incorrectly.

For example, a periprosthetic left hip fracture resulting from trauma would be coded first with S72.002D (Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing), followed by M97.02xD (Periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter).

The necessity of using two codes for these conditions was specified in the Q4 2016 Coding Clinic update, which cited guidance from the American Academy of Orthopaedic Surgeons in saying that periprosthetic fractures are not complications of joint prosthetics, as they were previously classified, but rather a fracture of the bone around the area of the prosthesis.

Periprosthetic fractures, like other fractures, may be caused by trauma or an underlying disease process (pathological) and the code for the specific fracture must be assigned first, followed by the code from M97.- indicating it’s a periprosthetic fracture, according to the Coding Clinic.

Tip: Do not assign a code from T84.01- (Broken internal joint prosthesis) for a periprosthetic fracture, according to the Coding Clinic. Codes from the T84.01- category capture complications of joint prosthetics involving the breakage of the prosthetic itself. A periprosthetic fracture does not involving a break of the prosthetic, but the bone around the prosthetic.

Tip: Note that like the traumatic or pathologic fracture codes, M97.- codes require a seventh character (“A,” “D” or “S”) to indicate the nature of the encounter. A code that requires a seventh character isn’t valid without it and it must be placed in the seventh position, according to coding guidelines. [I.A.5]

CMS video tutorials on GG items offer new OASIS training resource for clinicians

Collect information from multiple sources when responding to GG0110 (Prior device use). Doing so will help ensure more accurate responses.

This is one key takeaway from a set of four short video tutorials CMS promoted this week on its website this week. The videos are designed to help with appropriate scoring of items GG0110, GG0130 (Self-care) and GG0170 (Mobility).

CMS has previously held in-person provider trainings and issued quarterly OASIS Q&A guidance to help dispel confusion around these items. The videos — which were originally posted to the CMS YouTube channel in March and May — are the latest resources designed to educate agencies and clinicians on appropriate scoring of these GG items.

But some of the examples used in the videos would have been significantly improved with additional detail, contends Jennifer Sandel, co-owner of Home Care Service Solutions LLC in Battle Creek, Mich.

For instance, it would be helpful to have an example demonstrating a patient who refuses to complete an activity, but through observation of other tasks or interview of the patient or caregiver, the clinician is able to determine an appropriate response, says Amanda Gartner, RN, BSN, MSN, COS-C and clinical analytics manager with Overland Park, Kan.-based The Corridor Group.

“I feel this is where agencies seem to struggle the most,” Gartner says.

Scenario: Traumatic periprosthetic fracture, bike accident

A 66-year-old man who underwent knee replacement surgery on his left knee six months ago hit a car while riding his bicycle in traffic and suffered a periprosthetic fracture of his left tibia in the accident. He underwent surgery and is admitted to home health to continue his recovery. Additional diagnoses include pernicious anemia and osteoarthritis in the right knee.

Rationale:

• The fracture occurred in a bicycle accident and is thus a traumatic periprosthetic fracture. The code for the traumatic fracture is assigned first, followed by the code for the periprosthetic fracture, in accordance with Coding Clinic guidance.
• Fractures are still coded as fractures, even if they’re treated surgically. No surgical aftercare code should be assigned in this scenario.
• Pernicious anemia is coded as a relevant comorbidity.
• The patient’s right knee osteoarthritis can be coded as primary even if it wasn’t specifically documented, according to Coding Clinic guidance.
• The status code Z96.652 captures the presence of the patient’s left knee prosthetic.
• The external cause code V13.9xxD communicates how the patient sustained the traumatic periprosthetic fracture. It carries the same seventh character as the trauma code it is helping to describe, in accordance with coding guidelines.

Coding COPD shouldn’t take your breath away

Chronic obstructive pulmonary disease (COPD) and its numerous associated conditions can be confusing. Accuracy begins with a search in the alphabetic index under the main term “Disease, lung.”

In addition, a search under “Disease, pulmonary” will point coders to see also Disease, lung.

J44.9 (Chronic obstructive pulmonary disease, unspecified) is within Chapter 10 (Diseases of the Respiratory System). However, the subterms indented under “with” direct coders to more specific J codes within the same section — Chronic lower respiratory diseases (J40-J47). An example of this is J44.1 (Chronic obstructive pulmonary disease with (acute) exacerbation).

The J44.- category (Other chronic obstructive pulmonary disease) contains most of the codes that capture the multiple types of COPD. Many of these codes, such as asthma with chronic obstructive pulmonary disease and chronic obstructive tracheobronchitis, are listed under the Includes note. Note that many of these conditions require the term “obstructive” as part of the diagnosis to meet the criteria for J44.

As stated above, J44.9 captures COPD without further specification. Code J44.1 denotes exacerbated COPD. Regardless of treatment or medication changes, the provider must document COPD as exacerbated or decompensated to assign J44.1. COPD accompanied by a lower respiratory infection is captured with J44.0. Examples of lower respiratory infections are pneumonia and bronchitis.

The Excludes 1 note for this category is extremely helpful when deciding if a J44 code — versus another J code — is appropriate. An Excludes 1 note is a pure excludes note. It means “NOT CODED HERE!”

An Excludes 1 note indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note. The exception, of course, is a circumstance when the two conditions are unrelated to each other (ICD-10-CM Official Guidelines for Coding and Reporting FY 2019). Examples listed under the J44 Excludes 1 note are J47.- (Bronchiectasis) and J42 (Chronic bronchitis NOS).

Don’t let OASIS-D1 changes reduce the quality of your comprehensive assessments

While OASIS-D1 will make responses to 23 existing items optional, agencies must keep in mind that the OASIS is only one piece of the assessment puzzle.

The revised Home Health Conditions of Participation (CoPs) require each patient receive a patient-specific comprehensive assessment provided by the agency [§484.55; G510].

Removing items or making items optional doesn’t necessarily eliminate the need to assess the information.

“We still have a comprehensive assessment to complete. The CoPs don’t change,” says Lisa Selman-Holman, JD, BSN, RN, president of Selman-Holman & Associates in Denton, Texas.

To comply with the CoPs, the comprehensive assessment must at least include:

• The patient’s current health, psychosocial, functional and cognitive status [§484.55(c)(1); G528];
• The patient’s strengths, goals and care preferences [§484.55(c)(2); G530];
• The patient’s continuing need for home care [§484.55(c)(3); G532];
• The patient’s medical, nursing, rehabilitative, social and discharge planning needs [§484.55(c)(4); G534];
• A review of all medications the patient is currently using [§484.55(c)(5); G536];
• The patient’s primary caregiver and other available supports [§484.55(c)(6); G538];
• The patient’s representative [§484.55(c)(7); G540]; and
• Incorporation of the current version of the OASIS items [§484.55(c)(8); G542].
• Clinicians must follow best practices to ensure that at minimum each of these elements is included in their assessments, regardless of the items required by the OASIS.

“The OASIS should not drive our assessment, the patient should drive our assessment as well as best practices and standards of care,” says Karen Tibbs, RN, MS, HCS-D, COS-C, quality and education manager with Wayne, Pa.-based McBee Associates.

Without items serving as a reminder, however, there is a chance that clinicians simply won’t assess certain information, Tibbs contends.

Scenario: COPD with exacerbation

An elderly male patient is admitted to home health following an acute exacerbation of his COPD. Provider documentation indicates patient has two additional days of oral antibiotics for pneumonia. He is a nonsmoker with no history of tobacco use. However, his wife of 50 years is a heavy cigarette smoker.

Rationale:

• Coders should assign J44.1 and J44.0 when COPD is documented as both exacerbated and with a lower respiratory infection, according to Q3 2016 Coding Clinic guidance. J18.9 is added to identify the infection per the instruction located under J44.0.
• A “Use additional code to identify” instruction is located under J44.- to assign exposure to tobacco smoke.

Let the type of surgery guide your aftercare code choice

Assign Z48.812 (Encounter for surgical aftercare following surgery on the circulatory system) for a patient who’s receiving surgical aftercare following a coronary artery bypass graft (CABG).

That’s because a CABG procedure is performed on the circulatory system, and ICD-10 surgical aftercare codes are largely grouped by the body system on which the surgery was performed.

To find a surgical aftercare code by body system, search the alphabetic index under “aftercare,” scroll to “following surgery (for) (on)” and then locate the specific body system involved.

For example, for a patient who underwent lung surgery to treat COPD, search under “aftercare, following surgery, respiratory system,” which will lead to Z48.813 (Encounter for surgical aftercare following surgery on the respiratory system).

Aftercare codes Z48.812 and Z48.813 are both found in the Z48.81- subcategory (Encounter for surgical aftercare following surgery on specified body systems). The subcategory also offers six more codes for separate body systems.

CMS announces OASIS-D1; latest version of the assessment to take effect in 2020

Less than a year after the implementation of OASIS-D, CMS is already looking ahead to a new version of the assessment. The updates are expected to take effect Jan. 1, 2020.

CMS announced OASIS-D1 on its April 3 home health, hospice and durable medical equipment (DME) open door forum and released additional details on the new version of the assessment in May.

As part of the change to OASIS-D1, existing items M1033 (Risk for hospitalization) and M1800 (Grooming) will be added to the assessment at follow-up. This is happening because both items will be used to calculate functional impairment levels under PDGM, which takes effect on or after Jan. 1, 2020.

Twenty-three other existing items will change from required to optional at specified time points.

Agencies also will be able to enter a new response option of an equal sign (=) for these 23 items at the specified time points.

Further changes to the OASIS can be expected in the coming years based on measures already being tested because of the IMPACT Act.

Scenario: Surgical repair of hip fracture

A 69-year-old woman fell down a short staircase in her home, causing her to sustain a right hip fracture, which was repaired surgically in an open reduction internal fixation (ORIF) procedure.

She is admitted to home health for surgical aftercare. Her comorbidities include diabetic PVD and glaucoma.

Rationale:

• Aftercare codes are not used for injuries, even when treated with surgery, according to coding guidelines.
• Thus, the fracture code is assigned with the seventh character “D” to indicate the subsequent nature of the encounter, in accordance with coding guidelines.
• Diabetic PVD and glaucoma are relevant comorbidities that could impact the patient’s recovery and are thus coded as additional diagnoses.
• There is no assumed relationship between diabetes and glaucoma. Thus, the diagnoses are coded separately as no link is provided.
• An external cause code is assigned to help describe how the patient sustained the fracture. It carries the same seventh character code as the injury, in accordance with coding guidelines.

Assign diabetes mellitus combination codes, avoid coding errors

When coding for diabetes with an associated manifestation, check for an existing combination code. Otherwise you risk coding incorrectly, which could cause further scrutiny if it occurs frequently.

While diabetes mellitus is one of the most common home health diagnoses, it is also one of the most commonly miscoded diagnoses due to failing to assign the combination codes for diabetes mellitus with associated manifestations, industry experts say.

ICD-10 guidance released from Coding Clinic 2016 clarified that it was incorrect to code diabetes separately from associated manifestations. Yet some coders incorrectly assign separate codes for diabetes with associated conditions because the documentation doesn’t link the two and the coders don’t want to “diagnose” the patients themselves, says Sherri Parson, HCS-D, director of staff development for coding outsourcer Quality in Real Time of Floral Park, N.Y.

Coders should automatically connect those conditions unless the physician specifically states otherwise in the documentation. The classification makes that assumption, not the coder, Parson says.

When you search for diabetes in the alphabetic index, all the potentially associated manifestations are listed underneath the word ‘with.’ When documentation states that the patient has diabetes and one of the associated manifestations, a relationship is assumed between those two conditions, resulting in one combination code.

Tip: Unless the doctor specifies that diabetes and one of the associated manifestations are unrelated, always assume they are connected and code them together.

New items again dominate guidance in April release of CMS quarterly OASIS Q&As

Guidance on new items capturing information on falls, mobility, self-care and prior device use took center stage in the second set of quarterly OASIS Q&As that CMS issued since OASIS-D took effect Jan. 1

Of the 15 questions included in the April release, 14 deal with these new items.

“This is kind of what I expected to see: some clarification on GG items that we didn’t have before,” says Karen Tibbs, RN, MS, HCS-D, COS-C, quality and education manager with Wayne, Pa.-based McBee Associates. “This is good, but to be expected. With every release we should get these clarifications and update the guidance library.”

One such clarification can be seen in the response to Question 3, which asks how to respond to GG0130B (Self-care, Oral hygiene) when the patient has no teeth or dentures.

In the response, CMS explains GG0130B “may be applicable to an edentulous patient (a patient without teeth) and could be coded using one of the six performance codes.”

“These are circumstances that probably happen quite frequently, so agencies need to really pay attention and make sure they get this guidance out to their staff,” Tibbs says.

Scenario: Secondary diabetes mellitus, pancreatectomy (hypoinsulinemia)

A patient is referred to home care due to pain in his legs, unable to ambulate, and falling due to diabetic angiopathy. He has diabetes due to having his entire pancreas removed. He requires insulin.

Rationale:

• Postpancreatectomy diabetes mellitus — lack of insulin due to surgical removal of all or part of the pancreas is coded with E89.1 (Postprocedural hyperinsulinemia).
• Per guidance at E89.1, E13.51 captures the diagnosis of other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene. Because the lack of a pancreas caused the lack of insulin, code the absence of the pancreas.
• The patient now requires insulin, so Z79.4 is assigned for long term (current) use of insulin.
• A history of falling is also noted in the documentation, therefore Z91.81 must be assigned as well.

Coders: Get documentation in order to be ready for the new payment model

You must assign M19.90 (Unspecified osteoarthritis, unspecified site) for a patient whose physician has only diagnosed “osteoarthritis” — even if the physical therapist’s assessment states that the osteoarthritis (OA) is affecting the right shoulder.

Otherwise you risk a coding error.

The more specific code, M19.011 (Primary osteoarthritis, right shoulder), can be assigned instead only if the physician diagnosed OA in the right shoulder or if the physician confirms that additional detail in response to a query, says Trish Twombly, HCS-D, a coding expert and independent home health consultant based in Dallas.

Without detail indicating a specific joint, a diagnosis of osteoarthritis must be coded with the unspecified M19.90, according to the alphabetic index and Q4 2016 Coding Clinic guidance.

However, it will be unacceptable to code M19.90 as a primary diagnosis when the new payment system, the Patient-Driven Groupings Model (PDGM), takes over on or after Jan. 1, 2020. That’s the case even though unspecified osteoarthritis, unspecified site is among the most commonly assigned primary diagnoses, Twombly warns.

This is just one example of why agencies must start improving their documentation policies now so that they can both assign more specific codes and have the necessary documentation to back those codes up.

“This is the time for us as an industry to clean up our act,” Twombly says.

Take steps to ensure accuracy on OASIS-D item GG0100, assess prior function

Understand how to accurately respond to a new item assessing prior functioning now that OASIS-D is in effect.

Accuracy on GG0100 (Prior functioning) — implemented as part of OASIS-D on Jan. 1, 2019 — is crucial because the item plays a part in justifying the need for therapy, contends Jennifer Sandel, MPT, HCS-O, co-owner of Home Care Services Solutions in Battle Creek, Mich. The item serves as a replacement for M1900 (Prior functioning), which appeared on OASIS-C2.

GG0100, like M1900 before it, serves as a baseline and helps establish the need for physical therapy and occupational therapy, Sandel explains.

But many clinicians struggled with M1900, and may have some of the same challenges with the new GG0100.

The biggest hang-up when it comes to M1900 was the concept of assistance. For this item, CMS considered assistance to be only human assistance, Sandel says.

A patient could be deemed independent for the OASIS-C2 item if she used an assistive device to complete an activity, but requires no assistance from a helper, according to the OASIS-C2 guidance manual.

The same concept applies to GG0100. Once again, the patient is considered independent if she can complete the activity “with or without an assistive device” and without assistance from a helper.

Scenario: CABG, diabetes, arthritis

A 73-year-old man recently underwent coronary artery bypass surgery to treat severe coronary artery disease. He is admitted to home health for surgical aftercare. His comorbidities include diabetes, for which he takes oral hypoglycemic medication, and arthritis, for which his physician ordered physical therapy. The physical therapist’s assessment indicated that the arthritis affects his knees. However, the physician’s documentation doesn’t include this detail and the call to the physician’s office seeking confirmation was not returned.

Rationale:

• As the focus of care, surgical aftercare following the CABG is coded in the primary position.
• Though the CABG procedure treats coronary artery disease, it does not cure it. Therefore, the condition is still coded.
• Diabetes and arthritis are important comorbidities that will impact his recovery and are coded as secondary diagnoses.
• Coding guidelines require the diabetes to be coded as Type 2 because the type wasn’t specified, and for the patient’s use of oral hypoglycemic medication to be captured with Z79.84.
• Though the patient’s arthritis was documented by the physical therapist as affecting his knees, this was not corroborated in the physician’s documentation and a call seeking confirmation was not returned. Therefore, it must be coded with M19.90, according to coding guidelines and Coding Clinic guidance.

Don’t strain when it comes to influenza coding

Codes for influenza are located in Chapter 10 (Diseases of the Respiratory System). It is important that we understand as coders to only code confirmed cases of influenza.

Per coding guidelines, “confirmation” does not require documentation of positive laboratory testing specific for avian or other novel Influenza A, or other identified influenza virus. However, coding should be based on the provider’s diagnostic statement that the patient has avian influenza or other novel Influenza A for category J09, or has another particular identified strain influenza, such as H1N1 or H3N2, but not identified as novel or variant,category J10. [1.C.10.c]

When coding influenza, we must code to the highest level of specificity for the type, subtype and associated manifestations. A search in the alphabetic index should begin with the term “influenza.” If you begin with the term “flu,” the alphabetic index will instruct you to “see also influenza.” Under the term “influenza,” we have choices for specific types and strains of the flu as well as codes to further specify any specific manifestations associated with influenza.

If the provider documents “suspected,” “possible” or “probable” avian influenza, or novel influenza, or other identified influenza, use the appropriate code from category J11 (unidentified influenza virus). [1.C.10.c]

This specific guideline may confuse some coders. It is important to clarify that this guideline refers to cases where the physician confirms the diagnosis of influenza; however, the specific type of influenza is only “suspected” or “probable.”

The J11 code category also applies when documentation from the physician indicates “flu” or “influenza” as a confirmed diagnosis but gives no further detail. J11.1 is the default code for influenza NOS.

J09 (Influenza due to certain identified influenza viruses) is used when influenza due to the novel Influenza A virus is confirmed. This is not the correct code to use when Influenza A is documented; the key here is novel Influenza A.

J09 is the correct code category used to report human influenza cases due to novel Influenza A viruses occurring in pigs or other animals that have not been previously found in humans when it is occurring with gastrointestinal manifestations caused by the novel Influenza A virus, such as gastritis, enteritis and gastroenteritis.

Only provider-confirmed cases of avian or bird influenza, swine influenza, influenza of other animal origin, not bird or swine, or Influenza A/H5N1 should be coded using the J09 category. This category has a place hold X in the fourth position and requires a fifth character to specify the associated manifestations. J09.X2 is the default code for influenza due to identified novel influenza A virus NOS.

J10 is the correct category for influenza due to other identified influenza viruses. If the influenza is identified as Influenza A but not documented as novel, this is the correct code category. Use this code category when documentation identifies another particular identified strain of influenza, such as H1N1 or H3N2, but the virus is not identified as novel or variant. This is also the correct category for Influenza B or C.

J10.1 is the default code for influenza due to other identified influenza virus NOS.

CMS releases updated OASIS-D errata that matches most info from July errata

Many corrections outlined in the OASIS-D errata released in July 2018 weren’t present in the final guidance manual, leaving some confusion about what guidance agencies were supposed to follow.

But on Jan. 25 — about a month after the 335-page final OASIS-D guidance manual was released — CMS posted an updated errata reiterating the changes from the original errata.

While CMS confirmed to DecisionHealth that the July errata superseded the final manual, a notification wasn’t posted publicly.

The January errata contains 12 changes. Those changes were all outlined in the original 17-item July errata but did not appear in the final manual.

Among the repeated guidance is language around the physician-ordered resumption of care (ROC) date. The manual states the physician-ordered ROC should be conducted “on or within two calendar days of the physician-ordered ROC date.”

The statement raised questions for many industry experts because it didn’t align with guidance around physician-ordered start of care (SOC) dates, which must be a specific date and not a date range. The statement also appeared to conflict with other guidance within the manual.

The updated errata once again states the ROC visit must be conducted on the actual physician-ordered ROC date.

But because the July errata was published before the final guidance manual and CMS did not publicly announce that the earlier errata superseded the final manual, it’s possible that agencies may have followed the wrong guidance in the first 25 days OASIS-D was in place.

If agencies conduct a ROC visit outside the 48-hour window and after the physician-ordered ROC date, they would be out of compliance with timely initiation of care. That would negatively impact the agency’s performance on that measure.

Agencies also would be out of compliance with the revised Home Health Conditions of Participation (CoPs), which allow a ROC date within 48 hours of the patient’s return home from a hospital admission of 24 hours or more, or on a physician-ordered ROC date [§484.55(d)(2); G548].

If agencies made this mistake before the updated errata was released and get cited for it, all hope is not lost, contends attorney Robert Markette of Indianapolis-based Hall, Render, Killian, Heath & Lyman.

“If in that window where guidance was in conflict, I think you could make the argument on appeal,” Markette says.

When in doubt about potentially conflicting guidance, however, Markette recommends sticking with what’s in the CoPs.

Scenario: Flu, pneumonia, COPD

A 75-year-old patient is admitted to home health after a hospital stay for Influenza B with pneumonia. The patient came home on Tamiflu and antibiotics. The patient also has COPD. The focus of home health is on the influenza and pneumonia.

Rationale:

• The patient is still being treated for the influenza with pneumonia and it is the focus of care, so it is coded as primary.
• Influenza B is coded to the J10 category.
• An additional code for pneumonia is not assigned because it is included in the influenza combination code. We do not have more specific information as to the type of pneumonia.
• Influenza is not considered a lower respiratory infection for the purposes of coding COPD with J44.0. But if influenza results in pneumonia, code the COPD as J44.0, and the influenza, and if known, also code the type of pneumonia.

Avoid the heat of burn coding errors, protect records

Assign T25.612D (Corrosion of second degree of left ankle, subsequent encounter) and not T25.212D (Burn of second degree of left ankle, subsequent encounter), for a patient with a second-degree burn on his left ankle caused by chlorine gas, or you will have coded incorrectly.

That’s because the patient’s burn resulted from the contact with a chemical, not heat.

The ICD-10 code set differentiates between burns caused by a heat source, called thermal burns, and burns caused by chemicals, which are referred to as corrosions, according to coding guidelines. [I.C.19.d]

Burn and corrosion codes are found in Chapter 19 (Injury, poisoning and certain other consequences of external causes) between T20 (Burn and corrosion of head, face, and neck) and T32 (Corrosions classified according to extent of body surface involved).

Codes are grouped by body site, with the fourth character indicating whether it’s a burn or a corrosion as well as the degree of skin damage. The fifth character further specifies the location of the injury.

For example, the T21.- category captures burns and corrosions of the trunk. If you drill down to subcategory T21.22- you’ll find codes for second degree burns of the abdominal wall while codes in the T21.73- subcategory capture third degree corrosions of the upper back.

Tip: Note that as injuries, codes for burns and corrosions require a seventh character (“A,” “D” or “S”) to indicate the nature of the encounter. The seventh character must be included on the code and in the seventh position in order for the code to be considered valid, according to coding guidelines. [I.C.19.a] [I.A.5]

Tip:Code a burn resulting from the swallowing of a corrosive or caustic substance as a corrosion burn, according to the alphabetic index.

Tip:Assign a burn documented as having produced full thickness skin loss as a third degree burn, according to the alphabetic index.

New OASIS-D items take center stage in January release of CMS quarterly Q&As

Many agencies are struggling with accuracy and productivity challenges associated with OASIS-D. But CMS quarterly OASIS Q&As may help eliminate some confusion around the revised assessment.

Industry experts say GG0130 (Self-care) and GG0170 (Mobility) are among the biggest hurdles for clinicians during the transition to OASIS-D. So it’s no wonder that 26 of the 32 new Q&As deal with the six items new to the OASIS, including GG0130 and GG0170.

“I truly believe that these [Q&As] are going to help some people,” says Arlynn Hansell, PT, HCS-D, HCS-H, HCS-O, COS-C and owner of Cincinnati-based Therapy and More, LLC.

CMS issued the new guidance Jan. 15, and the update contains more Q&As than were issued as part of quarterly updates in all of 2018 combined.

“I think it’s great that the industry is asking questions so that we can get clarification on how to answer these accurately,” says Amanda Gartner, manager of compliance and OASIS education with Overland Park, Kan.-based The Corridor Group.

Because GG0130 and GG0170 involve so many different components and have been such a challenge for clinicians, the various guidance around these items is among the most noteworthy in the January 2019 Q&A update, experts say.

In the Q&As, CMS also provides guidance on items capturing information on height and weight, wounds, medication management and active diagnoses.

Scenario: Non-healing infected burn

A 72-year-old woman burned the palm of her right hand on her stove three months ago, causing a third degree burn. Though the burn was treated right away, it has failed to heal and has now become infected with MSSA. Her physician has ordered wound care and eight weeks of oral antibiotics. A 75-year-old man is admitted to home health for treatment of an acute exacerbation of chronic systolic heart failure. He also has hypertension, stage 3 chronic kidney disease and his record lists pulmonary hypertension as well.

Rationale:

• The patient’s burn was sustained several months ago but is not healing and has now become infected. The non-healing burn is coded as an acute burn, in accordance with coding guidelines.
• An additional code is for the infecting organism is assigned to capture that the burn is infected with MSSA, in accordance with coding guidelines.
• The patient’s long-term use of antibiotics comes with certain risks and thus is coded with Z79.2.
• The external cause code, X15.0xxD is assigned to capture how the patient sustained the burn, in accordance with tabular instruction.

Pulmonary v. essential: All hypertension is not created equal

Be sure to both assign I10 (Essential (primary) hypertension) and I27.20 (Pulmonary hypertension, unspecified) for a patient with hypertension and pulmonary hypertension, or risk a coding error and leaving a potentially serious disease process out of a patient’s medical record.

Unlike essential hypertension, where one code (I10) covers the condition when it occurs by itself, there are multiple types and causes of pulmonary hypertension and the ICD-10 code set provides multiple codes to reflect this.

Codes for pulmonary hypertension are found in the I27.- category (Other pulmonary heart diseases), which offers a total of seven unique codes contained within two subcategories, I27.0 (Primary pulmonary hypertension) and I27.2- (Other secondary hypertension).

A diagnosis of primary pulmonary hypertension codes to I27.0, according to the alphabetic index. Secondary pulmonary hypertension refers to pulmonary hypertension that is due to some other disease process.

The alphabetic index provides paths to codes for pulmonary hypertension resulting from a variety of causes, such as hematologic disorders (I27.29, Other secondary pulmonary hypertension) and lung diseases and hypoxia (I27.23, Pulmonary hypertension due to lung diseases and hypoxia).

When assigning a code for secondary pulmonary hypertension, be sure to follow tabular instruction at the I27.2- subcategory level that instructs the coder to “code also” the underlying cause.

July errata supersedes recently released final OASIS-D guidance manual, CMS says

CMS released the final OASIS-D guidance manual less than two weeks before the new version of the assessment took effect. Not all expected changes were outlined in the final version.

In July 2018, CMS released an errata detailing 17 areas with identified errors to the draft guidance manual. The errata included corresponding revisions.

But only four changes outlined in the errata are reflected in the final guidance manual released Dec. 20, 2018. They include updating language around pressure ulcers and pressure injuries and correcting the spelling of the word “transfer” in GG0170F, which addresses toilet transfer.

The remaining issues remained unchanged in the 335-page final manual.

CMS has confirmed to DecisionHealth, however, that agencies should follow the updated language within the errata.

“Typically, the errata is not released until after the final manual however an exception was made this year due to the concern about new items,” a CMS spokeswoman told DecisionHealth. “All cumulative errata are then addressed in the next version of the manual. Providers should continue to follow the errata, which supersedes the final manual.”

Scenario: Hypertensive heart disease, pulmonary hypertension

A 75-year-old man is admitted to home health for treatment of an acute exacerbation of chronic systolic heart failure. He also has hypertension, stage 3 chronic kidney disease and his record lists pulmonary hypertension as well.

Rationale:

• The ICD-10 classification presumes relationships between heart failure, hypertension and chronic kidney disease. Thus, all three diagnoses are coded as connected, with the code for hypertension coded first, in accordance with tabular instruction.
• The code for acute on chronic systolic heart failure precedes the code for the stage 3 chronic kidney disease as the heart failure is the focus of care.
• The patient also has a diagnosis of pulmonary hypertension. Because pulmonary hypertension is a different disease process than essential hypertension, it is coded as a separate diagnosis with I27.20.

How to code neuroendocrine tumors

Begin your search for the right code for a patient’s malignant carcinoid tumor in the alphabetic index, not the Neoplasm Table, or risk a coding error.

For example, if you were to search in the Neoplasm Table under “colon” for a diagnosis of a malignant carcinoid tumor of the colon, and followed it to C18.9 (Malignant neoplasm of colon, unspecified), you will have assigned an incorrect code.

That’s because malignant carcinoid tumors are a specific type of cancer known as neuroendocrine tumors. These tumors grow in cells that make hormones and can occur in various areas of body including the organs of the digestive system, lungs, pancreas, ovaries and thyroid, according to WebMD.

And like certain other neoplasms, such as melanoma and leukemia, codes for malignant carcinoid tumors are not found in the Neoplasm Table. The codes are instead found in the alphabetic index.

For the above diagnosis, look under “tumor, carcinoid” scroll to “malignant” and then to “colon,” which will lead to C7A.029 (Malignant carcinoid tumor of the large intestine, unspecified portion).

Tip: Understand that neuroendocrine tumors can be malignant (cancerous) or benign, according to the Mayo Clinic.

Tip: Search the alphabetic index first, always, according to coding guidelines. If the code for the type of cancer you’re coding is found in the Neoplasm Table, the index will direct you there.

Tip: Code a neuroendocrine tumor that isn’t further specified with D3A.8 (Neuroendocrine tumor NOS), according to the alphabetic index.

CMS hosts two webinars on OASIS-D, provides overview and insights into changes

If a patient isn’t able to attempt transferring in and out of the car because no car is available, enter response “10 - not attempted due to environmental limitations” on GG0170G (Mobility, car transfer).

This tip is among the guidance detailed during a recent CMS webinar on the revised assessment. CMS hosted webinars on OASIS-D on Aug. 28 and Sept. 5. Each two-hour presentation took a deep dive into the assessment and guidance on how to respond to new items.

OASIS-D is scheduled to go into effect Jan. 1, 2019, and will involve removing 28 items, adding six new items and revising seven additional items.

Appropriate use of a dash was among the guidance reviewed during the webinars.

When scoring new items GG0170 (Mobility) and GG0130 (Self-care), clinicians need to keep in mind that CMS expects the dash use to be a rare occurrence.

Because there are six available responses designed to capture various activity levels and four additional responses to capture different reasons for not attempting an activity, the dash only should be used as a response if there is truly no information available.

If the patient refused, the item didn’t apply to the patient, there were environmental issues, or medical conditions or safety concerns didn’t permit the activity, then clinicians should select the corresponding response to capture the reason the item or component was not assessed. A dash wouldn’t be appropriate in these instances.

Scenario: Metastasized carcinoid tumor, carcinoid syndrome, pain

A 65-year-old woman has a carcinoid stomach tumor that’s metastasized to her bones, causing severe pain. Her physician’s H&P also indicates a diagnosis of carcinoid syndrome and has been experiencing symptoms including diarrhea and stomach pain. Pain control from the cancer-related pain is the focus of care.

Rationale:

• As the focus of care, the pain related to the cancer is coded in the primary position, in accordance with coding guidelines.
• The neoplasms causing the neoplasm-related pain are coded as additional diagnoses, in accordance with coding guidelines.
• Her additional diagnosis of carcinoid syndrome is assigned and sequenced after C7A.092, in accordance with tabular instruction.
• Because they are associated with carcinoid syndrome, the symptoms of diarrhea and stomach pain are not additionally coded, in accordance with coding guidelines

Code Parkinson’s and related conditions correctly or risk lost reimbursement

Capture a patient’s diagnosis of dementia due to Parkinson’s disease with codes G20 (Parkinson’s disease) followed by F02.80 (Dementia in other diseases classified elsewhere without behavioral disturbance), or risk leaving rightful reimbursement on the table.

New Q&As highlight shift in staging pressure ulcers when scabbing is present

Significant shifts in how to stage a pressure ulcer when scabbing is present and what information can be considered for a discharge OASIS were among hundreds of changes CMS made this month to OASIS Q&A guidance.

Based on the new guidance, if a clinician is treating a Stage 3 pressure ulcer during the episode, and at reassessment that pressure ulcer is covered with a scab, it is considered a healing Stage 3 pressure ulcer.

Scenario: Parkinson’s dementia

An 82-year-old woman has had Parkinson’s disease for several years and was recently diagnosed with dementia after exhibiting combative behavior and wandering off. The physician’s H&P describes the dementia as a manifestation of Parkinson’s. She is admitted to home health for management and teaching on new medications and the dementia disease process.

Rationale:

• The patient’s dementia with behavioral disturbance is a manifestation of her Parkinson’s disease. There it is coded first with G20 followed by F02.81, in accordance with Q2 2017 Coding Clinic guidance.
• Even though the dementia is the focus of care, the Parkinson’s disease must be coded first, in accordance with coding guidelines.
• An additional code (Z91.83) assigned to capture the patient’s wandering, in accordance with tabular instruction.

Sort out coding of symptoms & signs, keep records accurate

Follow specific coding guidelines and tabular instruction to ensure accuracy when coding signs and symptoms, or risk potentially costly coding errors.

OASIS-D guidance manual offers clarity on falls, environmental limitations

The OASIS-D draft guidance manual released July 3 offers valuable clarifications for agencies on how to respond to new items.

Scenario: Hemiplegia, dysarthria, dysphagia

A 73-year-old man comes to home health for physical, occupational and speech therapy for diagnoses of dysphagia, dysarthria and right-sided hemiplegia. He is right-side dominant. A query to his referring physician revealed that he had a stroke three weeks ago and those symptoms are all residuals from the stroke. The hemiplegia will require the most intensive service and is thus the focus of care.

Rationale:

• The patient’s dysarthria, dysphagia and hemiplegia have all been confirmed to be sequela of a previous CVA. Thus, they are coded as combination codes, according to coding guidelines.
• An additional symptom codes is assigned following I69.391 for the stage of dysphagia, in accordance with tabular instruction.
• A code for the patient’s insulin use is required as she is not a Type 1 diabetic.

Keep your eyes open to keep glaucoma coding in compliance

You may need more than one code to code a patient’s glaucoma correctly.

Commenters express concern about the potential for duplicated effort on OASIS-D

Adding GG0130 (Self-care) and GG0170 (Mobility) to the list of OASIS items that collect responses on activities of daily living (ADLs) will result in confusion for clinicians, data inaccuracy and potential red flags for auditors, commenters argue.

Scenario: Diabetes, glaucoma

An 87-year-old female is admitted to home health for management of her diabetes. She will begin insulin due to hyperglycemia and will need education on insulin administration. She also has neuropathy and PVD and is followed by ophthalmology due to open-angle glaucoma in both eyes, which is documented as low risk with borderline findings in both eyes.

Rationale:

• The patient has confirmed diagnosis of diabetes mellitus with hyperglycemia. This is coded primary as it’s the focus of care.
• The patient has comorbidities of neuropathy and PVD, both of which can be assumed to be connected to diabetes, based on the “with” convention.
• A code for the patient’s insulin use is required as she is not a Type 1 diabetic.
• The patient’s glaucoma diagnosis is an important comorbidity that will impact her care and recovery. Because it’s affecting both eyes, both eyes have the same type and stage of the disease and a bilateral code exists (H40.013), only the bilateral code is assigned, in accordance with coding guidelines.

Correctly code congenital conditions, avoid coding errors

It’s not necessary to assign additional codes for symptoms or manifestations that are part of a patient’s congenital condition.

Start laying groundwork now to lessen productivity drain under OASIS-D

With the added time home health experts anticipate OASIS-D will take and the amount of time many agencies expect to spend on training, it’s a good idea to start preparing for the new version of the assessment now.

Scenario: Pulmonic stenosis

A 67-year-old man recently underwent cardiac surgery, specifically a valvotomy procedure, to treat congenital pulmonic stenosis and is admitted to home health for surgical aftercare. The patient has undergone several types of these procedures in the past; the condition is treated by the surgical procedure but is not resolved. He also has stable COPD and is a former smoker.

Rationale:

• Surgical aftercare for a circulatory condition is the focus of care, necessitating assigning Z48.812 in the primary position.
• The patient’s congenital pulmonic stenosis is treated but not resolved by the surgery and is thus still coded as a relevant comorbidity.
• COPD is coded as a relevant comorbidity as well.
• The patient’s history of smoking is also coded, in accordance with tabular instruction.

Let the 7th character speak for injuries, avoid lost reimbursement

Code the patient’s injury — such as a fracture, a laceration or a burn — and not an aftercare code, or prepare to lose rightful reimbursement

The code for the particular type of injury the patient suffered and the seventh character that is required to accompany it will convey the nature of the encounter, according to official coding guidelines. [I.C.21.c.7]

This means that you’d assign S71.111D (Laceration without foreign body, right thigh, subsequent encounter) for patient coming to home health to treat the injury, according to the alphabetic index. This is true even if the injury was treated with surgery and the agency is providing surgical aftercare. [CPH, 1/16]

Assigning the seventh character “D” in a scenario like this communicates that you’re providing aftercare versus the initial treatment provided in the acute care environment, which would be captured with a seventh character of “A,” according to coding guidelines.

The concept of using a “D” to indicate aftercare or that a condition is healing or resolving is a difficult concept for some coders to grasp, says Lisa Selman-Holman, HCS-D, principal of Selman-Holman and Associates and the coding service CoDR — Coding Done Right in Denton, Texas.

In fact, in the FY2018 code update, tabular instruction was added at the Z48.- category level (Encounter for other postprocedural aftercare), where most surgical aftercare codes are found, that reinforces this rule.

The instruction is in the form of an Excludes 1 note which says, “Encounter for aftercare following injury - code to Injury, by site, with appropriate 7th character for subsequent encounter.” [CPH, 8/17]The instruction is in the form of an Excludes 1 note which says, “Encounter for aftercare following injury - code to Injury, by site, with appropriate 7th character for subsequent encounter.” [CPH, 8/17]

Remember that an Excludes 1 note prevents two codes from being listed together, according to coding guidelines. Thus, this note is saying that you shouldn’t be assigning a code from the Z48.- category if you’re coding surgical aftercare following an injury. [I.A.12.a]

Use CMS-provided training scenarios to help clinicians answers M2005 correctly"

Consider the following scenario for M2005:

During the discharge assessment visit, the RN reviews the patient’s medication list and confirms that no potential clinically significant medication issues are present.

In reviewing the clinical record, there is documentation that a drug regimen review was conducted earlier in the episode, and no potential clinically significant medication issues were identified.

There is no other documentation to indicate that potential clinically significant medication issues occurred during the episode of care.

Correct answer and rationale:

Response “9 – NA – There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications.”

There is documentation the agency looked for potential clinically significant medication issues via completion of a drug regimen review conducted since the start of care (SOC)/resumption of care (ROC) was completed, and no issues were found.

Scenario: Joint replacement for osteoporotic fracture

An 82-year-old woman comes to home health after a right hip replacement that was performed to treat broken hardware and non-union of an osteoporotic right femur fracture. The broken hardware was removed during the surgery; the non-union was repaired and the fracture is expected to heal normally. She will receive surgical aftercare for the incision, dressing changes and physical therapy. She also has hypertension and chronic systolic heart failure.

Rationale:

• Even though the fracture was treated with a joint replacement, the fracture is still coded, according to Coding Clinic guidance.
• As an osteoporotic fracture, it is coded as a combination code with osteoporosis, according to the alphabetic index.
• The seventh character “D” is used here because the non-union has been resolved and it is now expected to heal normally.

Don’t lose sight of the rules when coding blindness & low vision

Good physician documentation is the lens you need to see through in order to correctly code blindness and low vision conditions.

For example, category-level tabular instruction at H54.- (Blindness and low vision) requires you to "code first" the underlying cause of the patient’s blindness.

And, most codes within this category require a high level of detail regarding the category of vision loss, whether one or both eyes are affected and to what degree. For example, code H54.52A1 corresponds to Low vision left eye category 1, normal vision right eye.

Codes for blindness and low vision conditions are found in Chapter 7 (Diseases of the Eye and Adnexa), specifically within the section "Visual disturbances and blindness" where categories H53.- (Visual disturbances) and H54.- are housed.

A search in the alphabetical index under the main term "blindness" will direct the coder to the H54.- category. You also may search under "low" or "loss" and then scroll to "vision" and that will also lead you to codes within the H54.- category.

You will find more specificity if you scroll down and look under additional terms that are indented under the main term, such as those specifying laterality, when there is a distinction between visual acuity in different eyes and when blindness is defined in legal terms.

For example, searching under "blindness, legal (both eyes) (USA definition)" leads directly to H54.8 (Legal blindness, as defined in USA).

Expert answers agencies’ questions on OASIS-C2 pressure ulcer, mobility items

Following a recent DecisionHealth webinar about mastering OASIS-C2, agencies asked questions of expert Ann Rambusch, MSN, HCS-D, HCS-O, RN, president of Rambusch3 Consulting in Georgetown, Texas. Here are some of her answers.

Question: For skin pressure ulcers, do we downgrade them as they heal or not with the new OASIS-C2 requirements? We were told in past training if it starts at a Stage 4 and heals throughout care, we code it what it is as it heals. So, a Stage 4 could be down coded to a Stage 3, 2, 1 as it heals.

Answer: Do not "down code" or reverse stage a pressure ulcer as a way to document healing. Reverse staging does not accurately characterize what is physiologically occurring as the ulcer heals. Over time as the Stage 4 pressure ulcer heals and contracts it becomes less deep, wide and long. The tissues (muscle fat, dermis) that were lost due to the ulcer are never replaced with the same type of tissue. Even though the wound has granulated almost completely (i.e., it’s 95% granulated), the ulcer is not reverse staged. The ulcer may have healed almost up to the surface of the epithelium, but it is still a Stage 4 ulcer. Clinical standards require that the ulcer continue to be documented as a Stage 4 until it has healed. (Chapter 3, M1307 (Oldest Stage 2 Pressure Ulcer), OASIS-C2 Guidance Manual, 1/2017)

Q: What do we do when a muscle flap fails, is it now a pressure ulcer again or does it remain a surgical site forever? So, every flap graft that fails, [do] we eat the failed area as a new pressure area when it now becomes a pressure area again?

A: On the OASIS, a pressure ulcer treated with a muscle flap is no longer considered a pressure ulcer. It is reported as a surgical wound. If the muscle flap used to treat the pressure ulcer is not healing or the flap begins to fail, the wound should be considered a complicated surgical wound. Continue to report the wound as a surgical wound on M1340 (Surgical Wound).

If the muscle flap heals (edges are completely re-epithelialized and the incision is clean, dry and closed with no signs or symptoms of infection for at least 30 days) this becomes a scar and is no longer reported as a surgical wound. If a new lesion due to pressure forms on the area that has healed, it is reported as a new pressure ulcer and staged accordingly.

When you have a flap that is used to treat a pressure ulcer, remember the pressure ulcer was removed (excised) completely and the flap becomes the surgical wound. That wound heals, it goes through epithelialization and becomes a scar. If a pressure ulcer then forms on top of that, that is considered a new pressure ulcer.

Scenario: Fracture, glaucoma, legal blindness

An elderly male patient is admitted to home health following an intertrochanteric fracture of the left hip sustained from falling down stairs. The patient developed a stage 3 pressure ulcer to his left heel during the inpatient stay. Documentation indicates he is legally blind due to bilateral severe stage chronic angle-closure glaucoma. The physician ordered nursing and physical therapy for continued aftercare of the fracture and management of the pressure ulcer.

Code the scenario:

Rationale:

• The instruction located under H54.- blindness and low vision state, "Code first any associated underlying cause of the blindness. Since documentation indicates bilateral chronic angle-closure glaucoma is the underlying cause of the patient’s legal blindness, the glaucoma code is sequenced prior to the code for legal blindness.
• The U.S. definition of legal blindness differs from the WHO definition, therefore, H54.8 is used to capture legal blindness within the United States.

Avoid trauma when coding traumatic brain & spinal cord injuries

You need at least two codes to capture sequela caused by a traumatic brain or spinal cord injury — one code to capture the current problem (the residual, such as paraplegia) and a second code to capture the injury that caused the problem home health is treating (the traumatic brain or spinal cord injury).

For example, a patient who is suffering from blurred vision following a traumatic subdural hemorrhage requires both H53.8 (Other visual disturbances) for the blurred vision and S06.5x0S (Traumatic subdural hemorrhage without loss of consciousness, sequela) to show that the brain injury caused the blurred vision.

This is because coding guidelines specify that the sequencing of sequela, or late effects, involves first coding the nature of sequela (this means the residual condition), followed by the code for the injury which, though now healed, led to the residual condition. The injury code will carry a seventh character "S" to communicate that it’s now healed but left a sequela behind. [I.B.10]

The definition of a sequela is a residual effect of a disease, condition or injury that occurs after the acute phase of that disease, injury or illness has resolved.

Tip: Understand that there’s is no time limit on the use of a sequela code. The residual effect may be apparent early on or may occur much later, sometimes even years later. [I.B.10]

Cut through the confusion: Properly stage reopened pressure ulcers at start of care

Clinicians should not re-stage a reopened pressure ulcer as they would a new wound on OASIS-C2, something that is particularly important to remember at start of care.

A previously closed Stage 3 or Stage 4 pressure ulcer that is currently open again should be reported at its worst stage, according to response-specific instructions for M1311 in the OASIS-C2 Guidance Manual. Even so, some clinicians have expressed confusion over how to stage reopened pressure ulcers.

The confusion is in part because of separate, unrelated OASIS-C2 guidance that dictates once a pressure ulcer is completely covered with epithelial tissue, the wound is considered healed, and should no longer be reported as an unhealed pressure ulcer, believes Kelly Kavanaugh-Branam RN, HCS-D, HCS-O, BCHH-C, HCS-H Interim Quality Review Nurse, Brookdale Healthcare Services in Brentwood, Tenn.

Before OASIS-C2, clinicians did report healed pressure ulcers on the assessment, Kavanaugh-Branam says. She contends clinicians are getting caught up on this change in guidance and questioning whether to treat these pressure ulcers as clinically healed in other situations.

The term "healed" implies to clinicians that a wound has been fully restored to its previous, healthy condition, explains Jennifer Sandel, MPT, HCS-O, co-owner, Home Care Services Solutions in Battle Creek, Mich. That is not the case when it comes to pressure ulcers, though.

A reepithelialized pressure ulcer will only ever regain up to 80% of its tensile strength and therefore is never truly healed, according to Dea Kent, RN, NP-C, CWOCN director nursing home oversight & consulting, in Fishers, Ind. It isn’t clinical practice to reverse stage pressure ulcers because they don’t heal in reverse order and will never be completely restored, she says.

For this reason, Kent still uses the term closed when thinking about pressure ulcers because she says it is clinically accurate.

"We have to fit clinical assessment data into various tools that the government has given us to be able to take credit for payment," Kent says.

In the case of M1306 (Does this patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher or designated as Unstageable), if a shallow depth wound reopens on the area of a closed Stage 4 pressure ulcer, it must be staged at its worst historical stage, Kent says. It should then be staged as a Stage 4 and for M1306, Response 1 (Yes) is correct, according to Kent.

The issue is not isolated to M1306, though. It could impact other items, such as new OASIS-C2 item M1311, which is a case-mix item, Kavanaugh-Branam says.

Scenario: Dysphagia, hemiplegia resulting from TBI

A 67-year-old male patient was involved in a motorcycle accident five years ago that resulted in a diffuse TBI with right sided hemiplegia and dysphagia. He was recently hospitalized with worsening dysphagia and required the placement of a G tube for nutrition. He is referred to home health for skilled nursing to instruct the family on the G tube care, for speech therapy and for physical therapy. Therapy is the focus of care.

Code the scenario:

Rationale:

• As the residual conditions, the dysphagia and hemiplegia are coded before the sequela form of the injury code that led to those conditions.
• The injury, with a seventh character "S" is coded next.
• Since there’s no information as to whether this patient or is right or left hand dominant and the right side is affected, it’s coded as dominant.
• The external cause code is optional, but it helps provide a higher level of detail to show how the injuries occurred.

Relieve the pressure of coding surgically treated pressure ulcers

Continue to code a pressure ulcer treated with a skin graft as a pressure ulcer that’s unstageable with a code from the L89.-category (Pressure ulcer). Do not code it as a surgical wound.

For example, you’ll code a patient’s skin grafted pressure ulcer on the sacrum with L89.150 (Pressure ulcer of sacral region, unstageable) and not with a surgical aftercare code such as Z48.817 (Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue).

The coding of surgically treated pressure ulcers, such as those covered with skin grafts or muscle flaps, can be confusing because coding and OASIS do not match up in this area.

For example, on the OASIS, a skin graft-treated pressure ulcer is not captured as a pressure ulcer but instead as a surgical wound, according to the October 2016 CMS OASIS Q&As, which state that "covering a pressure ulcer with a skin graft changes it from a pressure ulcer to a surgical wound."

But coding guidelines clearly stipulate that pressure ulcers treated with skin or muscle grafts should be coded as unstageable pressure ulcers. The pressure ulcer is coded as unstageable because the graft prevents its stage from being clinically determined, according to coding guidelines. [I.C.12.a.2]

Tip : Code the donor site, if your agency is providing care for it, with Z48.298 (Encounter for aftercare following other organ transplant), coding experts say. The donor site is also captured as a surgical wound on the OASIS while it is still healing, according to the October 2016 Q&As.

CMS removes dozens of items from OASIS, adds items to comply with IMPACT Act

Many items will be eliminated from the OASIS and several others will be added to the assessment as part of CMS’ ongoing efforts to comply with the IMPACT Act.

In general, it’s a good thing anytime CMS works to make the OASIS less burdensome by removing items that don’t affect payment, the Home Health Conditions of Participation (CoPs) or other quality programs, says Gina Mazza, a partner at Fazzi Associates in Northampton, Mass.

That said, an individual assessment and care plan is required under the revised CoPs, which take effect Jan. 13, 2018. So, it may make sense to assess for things not included on the OASIS in order to tailor care to each patient, Mazza says.

In the rule posted Nov. 1, CMS finalized changes to 33 items — resulting in the collection of 235 fewer data elements at certain time points.

The changes equate to the complete removal of 31 items at time points CMS specified and the paring down of two other items, a CMS spokeswoman tells DecisionHealth.

CMS also will add or replace six OASIS items.

Despite the changes, the same assessment processes will apply, and clinicians are unlikely to save time, says Arlene Maxim, RN and vice president of program development with Quality in Real Time (QIRT) in Floral Park, N.Y.

Another OASIS change worth noting is that M1400 (Dyspnea) has been given one case-mix point effective Jan. 1. Previously it had no case-mix points.

Scenario: Pressure ulcer treated with a skin graft

A 76-year-old man was recently admitted to home health after undergoing surgery to treat a stage 4 pressure ulcer on his left heel with a skin graft. The surgical wound has not yet begun to epithelialize. He has depression and severe COPD, for which he requires supplemental oxygen. The donor skin site is still healing and will receive care as well. It has just started to epithelialize.

Code the scenario:

Rationale:

• Though a pressure ulcer treated with a skin graft becomes a surgical wound for the purposes of the OASIS assessment, it’s still coded as a pressure ulcer. Because it’s unstageable due to the skin graft covering the wound, it’s coded as unstageable, according to coding guidelines.
• His comorbidities of severe COPD and depression are coded as they have the potential to impact his recovery. While the COPD is noted as "severe," it’s not said to be exacerbated and is therefore coded with J44.9.
• Since the skin donor site is also receiving care, Z48.298 is assigned, and the wound is captured on the OASIS as a surgical wound.
• His use of supplemental oxygen is coded with Z99.81.

Bone up on anatomy knowledge to keep fracture coding accurate, efficient

Save time in your search for a fractured wrist code in the alphabetic index by scrolling first to the subterm "carpal bone" underneath "fracture, traumatic" before searching for the specific bone, such as pisiform, which will take you directly to the correct code S62.16- (Fracture of pisiform).

By contrast, if you first look for "pisiform" under "fracture, traumatic" you’ll find a note telling you to "see fracture, carpal, pisiform," forcing you to essentially start your search over.

Robust knowledge of bone anatomy is a key skill for accurate and efficient coding of fractures particularly in light of the sheer number of available code options, says Trish Twombly, HCS-D, senior director for DecisionHealth in Gaithersburg, Md.

No single code for a generic "wrist fracture" exists. Rather, there are well over 100 unique wrist fracture codes which are broken down by which wrist bone is fractured, what part of the bone is affected, whether it’s the patient’s right or left wrist and whether the fracture is displaced or non-displaced.

For example, S62.014D corresponds to Nondisplaced fracture of distal pole of navicular [scaphoid] bone of right wrist, subsequent encounter for fracture with routine healing.

Thus, a coder who knows that the pisiform and scaphoid are two of the eight separate bones that make up the wrist, which are known as the carpal bones, will be able to efficiently move through the index and quickly pinpoint the specific section of the tabular where the correct code will be found.

Tip: : Note that codes for fractured scaphoid bones are found in a separate subcategory (S62.0-, Fracture of navicular [scaphoid] bone of wrist) from the remaining seven carpal bones, which are found in S62.1- (Fracture of other and unspecified carpal bone(s)). The S62.0- subcategory codes allow for greater detail, capturing fractures of the distal pole, middle third and proximal third of the scaphoid bone, according to the tabular.

To fully understand GG0170C, participate in CMS’ new online provider training

Use CMS’ newly posted provider training materials to ensure clinicians fully understand what to mark on the OASIS when the patient can’t move from a lying position to sitting on the side of the bed.

GG0170C (Mobility) only has appeared on the OASIS since January 2017, so many clinicians don’t properly understand how to respond in these situations, contends Jennifer Sandel, MPT, HCS-O, co-owner of Home Care Services Solutions in Battle Creek, Mich.

GG0170C is important partly because the item is involved in risk-adjusting the quality measure "Percent of residents or patients with pressure ulcers that are new or worsened."

That pressure ulcer measure affects payments and will be publicly reported on Home Health Compare beginning in January 2019.

CMS’ training, posted Dec. 20, reviews topics based on questions from provider trainings between November 2015 and August 2016 about Section GG. A portion of the training walks home health agencies and other post-acute providers through scenarios about how to fill out GG0170C.

The scenarios will be useful to educate clinicians who struggle with the item, says Arlynn Hansell, PT, HCS-D, HCS-H, HCS-O, COS-C and owner of Cincinnati-based Therapy and More, LLC.

Many home health clinicians don’t fully understand M2003 in particular, so the scenarios CMS has outlined will be valuable for agencies to use to educate staff, says Jennifer Sandel, co-owner of Home Care Services Solutions in Battle Creek, Mich.

Sandel says most clinicians are hands-on, visual learners, so she recommends agencies compile the scenarios and act them out during a training session for clinicians.

GG0170C includes six response options if the activity may be completed and three response options if the activity wasn’t completed. A dash also is an acceptable response but would be used rarely, in situations such as if a patient transfers or dies before the assessment occurs.

For GG0170C, options for when the activity wasn’t completed are: "07 — Patient refused," "09 — Not applicable" and "88 — Not attempted due to medical condition or safety concerns."

A clinician would mark 09 if the patient didn’t perform the activity prior to the current illness, exacerbation or injury, according to the training.

For example, the training states, agencies should mark 09 if the patient has a pre-existing and ongoing need of a mechanical lift and is unable to sit on the side of the bed even with assistance.

Meanwhile, a clinician would mark 88 due to a new medical issue or safety concerns. For example, CMS’ training states, 88 would be used when the patient has a new compression fracture that requires bed rest.

Scenario: Osteoporosis, shoulder fracture

A 90-year-old woman with known osteoporosis was discovered to have a fractured right shoulder during a routine doctor’s appointment. She reports no recent trauma and doesn’t know how she fractured her shoulder. She is admitted to home health for nursing and physical therapy for the fracture. She also has severe chronic pain unrelated to the fracture and recently started on a new opiate analgesic medication, which will require monitoring.

Code the scenario:

Rationale:

• The patient’s fracture would not have occurred in someone with normal, healthy bones, and the patient is known to have osteoporosis. Therefore, her right shoulder fracture can be assumed to be related to her osteoporosis and coded as such with M80.011D.
• She also has a diagnosis of chronic pain, unrelated to the fracture, which will impact her recovery and so it is also coded.
• Her long-term use of opiate analgesics requires monitoring, so Z79.891 is assigned to capture this.

Use proper procedures to find neoplasm codes, avoid errors & stay in compliance

Begin your search for a neoplasm code first in the alphabetic index by looking under the tumor’s histology, and then consult the neoplasm table if necessary, or risk assigning an incorrect code for a patient’s cancer diagnosis. If you instead jump immediately into the neoplasm table, you could easily end up choosing an incorrect code, says Sherri Parson, HCS-D, director of staff education for Floral Park, N.Y.-based coding outsourcer Quality in Real Time. Learning how to use the alphabetic index and the neoplasm table correctly is a common source of confusion among coders. "We see our novice coders struggle with this so much," Parson says.

Consider a diagnosis of melanoma of the skin of the left breast. Correct procedure would involve first looking in the index under "melanoma," which is the tumor’s histology or cell type, scrolling to "skin" and then "breast (female)(male)," which leads to C43.52 (Malignant melanoma of skin of breast).

By contrast, if you first went to the neoplasm table and based on melanoma being a type of skin cancer searched under "skin" and then scrolled to "breast," you’d end up at C44.501 (Unspecified malignant neoplasm of skin of breast).

Furthermore, note that the C44.- category (Other and unspecified malignant neoplasm of skin) provides codes for basal cell carcinoma and squamous cell carcinoma, two distinct types of skin cancer, as well as unspecified skin cancer codes. Codes for melanoma aren’t found there.

Tip: Remember that the procedure of first looking in the alphabetic index before verifying the code in the tabular is instruction that’s taken directly from official coding guidelines [I.B.1]. For neoplasms that aren’t specified by their histology and that are generally referred to as neoplasms or cancer, the index will lead you to the neoplasm table.

New CMS OASIS scenarios provide clues for how to answer IMPACT Act item

CMS has released five scenarios to help clinicians correctly answer new OASIS medication questions that have been added to comply with the IMPACT Act and will be publicly reported.

CMS discussed this information as part of an Aug. 17 Home Health Quality Reporting call about the new OASIS items and how to properly respond.

M2001 (Drug regimen review), M2003 (Medication follow-up) and M2005 (Medication intervention) are quality measures needed to meet IMPACT Act requirements, and data collection for home health agencies began Jan. 1, 2017. The Drug Regimen Review measure will appear on Home Health Compare in October 2018.

With drug regimen review, three conditions must be met for the care episode to have a favorable result: Completion of a drug regimen review at the beginning of the episode, physician contact and follow-up if medication issues are identified and physician contact and follow-up each time significant medication issues are identified throughout the episode.

The numerator is the number of episodes where the desired process was provided, and the denominator is the number of episodes eligible for the desired process. The measure rate is the percentage of successful patient episodes.

Data collection on the items for long-term care hospitals, inpatient rehab facilities and skilled-nursing facilities begins in 2018, with public reporting in 2020, according to CMS’ slides from the call.

Many home health clinicians don’t fully understand M2003 in particular, so the scenarios CMS has outlined will be valuable for agencies to use to educate staff, says Jennifer Sandel, co-owner of Home Care Services Solutions in Battle Creek, Mich.

A common reason why clinicians mark "0 - No" on M2003 is the challenge of getting physicians to respond by midnight of the next calendar day.

But there are simple steps agencies can take to increase their odds of accomplishing what CMS expects of providers and physicians as part of the OASIS item, industry experts contend. For instance, stress the need for clinicians to follow up with physicians’ offices if they haven’t heard back by the next day.

Two scenarios discussed during the call involve agencies that identified a medication issue and tried alerting the doctor in a timely manner but didn’t get a timely response. Clinicians in these scenarios should mark "0 – No" on M2003, CMS indicated.

Consider scenarios for M2001, M2003

Scenario 1: Late Friday afternoon during your resumption of care (ROC) visit, you identify a potential clinically significant medication issue you believe needs timely attention. You leave a message with the physician’s answering service before you leave the patient’s home, and you leave a second message Saturday.

The physician calls back Monday morning, telling you to have the patient discontinue the medication. You relay the information to your patient by phone and confirm he understood the direction during a home visit Monday afternoon.

Answer: Respond "1 – Yes, issues found during review" because the medication issue was clinically significant, CMS says. Respond "0 – No" on M2003 because even though the physician was notified and the issue was resolved, completion of recommended actions didn’t occur by midnight of the next calendar day.

Scenario 2: During the start-of-care (SOC) comprehensive assessment, the RN completes the drug regimen review and identifies a potential clinically significant medication issue. On that day of admission, the RN leaves a voicemail with the physician’s office about the issue.

The physician responds after midnight the next calendar day. No other medication issues arise during the episode, and the patient is discharged.

Answer: On M2001, respond "1 – Yes, issues found during review," CMS says. Answer "0 – No" on M2003 and M2005.

The issue was potentially significant and required physician contact by midnight of the next calendar day, CMS notes. Again, while the clinician tried to speak with the physician’s office about the issue, contact didn’t occur timely.

Forum details frequency of responses

On M2001, clinicians responded "0 – No" on 76% of SOC and ROC assessments in the first quarter of OASIS data collection for the item, officials said during the webinar.

Clinicians responded "1 – Yes, issues found during the review" on 23% of assessments.

Clinicians responded "9 – NA, Patient is not taking any medications" on 0.22% of assessments.

M2001 was reported with a dash on 0.15% of assessments.

Despite the data, a far larger percentage of patients actually do have medication issues, Sandel contends.

Such a low percentage of assessments where "Yes" is marked indicates clinicians don’t completely understand what "clinically significant" medication issues are, don’t understand what M2001 asks and/or don’t properly check medication, Sandel adds.

On M2003, meanwhile, clinicians responded "0 – No" on 15% of SOC and ROC assessments. Clinicians responded "1 – Yes" on 85% of assessments.

The "No" response should be listed more than 15% of the time on M2003, but many clinicians misunderstand the item, Sandel says.

For instance, she contends, many clinicians think they need to contact the physician (or physician designee) timely but don’t realize they also need to hear back and complete prescribed/recommended actions timely.

Do this to avoid a "No" on M2003

• Educate field clinicians about how to get doctors’ offices to respond sooner to calls about medication.

  If clinicians identify medication issues during an assessment at noon and leave a message that afternoon but don’t hear back, they should call the doctor’s office the next morning, advises Jessica Cook, coding and OASIS manager for BlackTree Healthcare Consulting in Conshohocken, Pa.

  Stress a return call is necessary — and give a deadline to respond, Cook says. For instance, the clinician could tell physician’s office staff, "If at all possible could I get some direction on how the doctor wants me to handle this by tomorrow afternoon?"

  Don’t expect a timely response if you don’t ask for one when you call and report an issue, says LaDawn Pierce, QAPI administrator for Mays Home Care, which serves Texas and Oklahoma.

• Understand that weekends are not an excuse:

  If the on-call physician directs you to monitor the patient and wait until Monday when the primary doctor is available, you can answer "yes" on M2003, says Ann Rambusch, president of Rambusch3 Consulting in Georgetown, Texas.

  Note that many doctors rotate who is on-call for important issues that must addressed outside regular business hours.

  But for doctors who don’t take calls after hours, arrange a meeting with them and explain the process measure, Pierce says. Explain the importance of coordinating care and that it’s vital to improve outcomes and prevent potentially avoidable hospitalizations.

  "Ask that physician for a contingency plan and his/her preferred method addressing clinically significant medication issues that occur outside of normal business hours," Pierce says.

  If the patient comes to your agency from a hospital at night or on the weekend, ask the discharge planner who you can contact if you identify clinically significant medication issues, she adds.

• Remember the window for a response isn’t 24 hours. Agencies actually have from the visit one day until midnight the following night "for the two-way communication and completion of the recommended actions to occur," Linda Krulish, president of OASIS Answers, Inc., said while educating providers during the call. CMS wants the response by midnight of the next calendar day, not midnight of the next business day.

• Understand the issue must be "significant" or there’s no need to call the doctor. Clinicians should use their judgment to determine if the medication issue is potentially significant, Rambusch says.

  "Physicians get lots of calls," she reminds. "Don’t waste their time if in your judgment this does not rise to a potentially significant issue."

  If you habitually call with insignificant issues, physicians will stop responding, Rambusch says.

  If a clinician identifies potential drug interaction issues but believes the physician has previously identified these issues as well and doesn’t have a problem with them, there’s no need to call the doctor, Sandel says.

  But life-threatening drug interactions should lead to calls to doctors — and so should issues where there’s a gray area about whether a call is necessary, Sandel says.

  Consider calling top referral sources and asking them for examples of situations when they’d want to be called about medication issues and when they would not, Sandel adds.

• Conduct drug regimen reviews and assessments in the first part of the day. This gives you more time to get a response from the physician, Rambusch says.

• Remind clinicians what to do when the doctor has no new orders or instructions. If clinicians report the issue to a physician timely, and the physician’s office responds timely with no new recommendations, the clinician should mark "1 – Yes," Krulish says.

Scenario: Anemia due to liver cancer

A 57-year-old man is admitted to home health with a primary diagnosis of anemia caused by his hepatocellular carcinoma of the liver. His medical record indicates that he is has chronic hepatitis C infection, is a former IV drug user and that his opioid dependence is currently in remission.

Code the scenario:

Rationale:

• Even though the focus of care is on the anemia, because it’s caused by cancer, the cancer is coded first, in accordance with tabular instruction.
• The histology of the patient’s cancer is specified as hepatocellular carcinoma, and an index search under those terms leads specifically to C22.0, making that the correct code.
• His chronic hepatitis C infection, as well as his opioid dependence in remission, are relevant to his plan of care and are thus coded as comorbidities.

Bring CDI to your agency to ensure coding accuracy, protect against audits

Learn how the documentation you use to assign ICD-10 codes could undergo a stringent QA and improvement process before the record ever reaches your desk. This is what CDI, or clinical documentation improvement, can do.

Think of CDI as a cog in the wheel of information governance, which is an emerging discipline in healthcare that focuses on how an organization ensures information is complete, accurate, trustworthy and usable, says Trish Twombly, HCS-D, senior director for DecisionHealth in Gaithersburg, Md.

CDI programs trace back to the 1990s when they were developed to help physicians with their documentation in acute care settings, Twombly says.

In contrast with what the home health industry thinks of as QA procedures, CDI is done concurrently with the admission for conflicting, incomplete or nonspecific documentation as opposed to an after-the-fact review, she says. It’s an audit of the documentation in the record before it gets to the coder’s desk.

Professionals who specialize in the practice of CDI currently work in hospitals and other acute settings and carry their own unique credentials, such as the CCDS (Certified Clinical Documentation Specialist) from the Association of Clinical Documentation Improvement Specialists (ACDIS).

These professionals help ensure that medical record documentation complies with applicable laws and official coding guidelines, as well as substantiates claims and safeguards rightful reimbursement for the organization, Twombly says.

Implementing documentation improvement initiatives within your agency could be the keys to its very survival.

"Documentation is the biggest problem this industry has," says Arlene Maxim, a home health expert based in Troy, Mich.

Maxim works on appeals for agencies, a position that allows her to see numerous records daily. Denials are occurring for inadequate documentation, she says.

The wave of documentation improvement that was supposed to arrive with ICD-10 to allow for the assignment of the far more specific codes has now dropped off, she says.

"ICD-10 should have forced documentation to improve, but it didn’t," she says. CDI programs are now what is needed within the industry to stave off widespread denials and serious financial penalties.

And while it may be hard to convince administrators who are already feeling the impact of tightening reimbursements and increased regulations, making investments to improve documentation really isn’t an option for an agency that wants to stay in business, Maxim says. "If agencies can’t afford to do CDI, they might as well close their doors."

To fully understand GG0170C, participate in CMS’ new online provider training

Use CMS' newly posted provider training materials to ensure clinicians fully understand what to mark on the OASIS when the patient can’t move from a lying position to sitting on the side of the bed.

GG0170C (Mobility) is important partly because the item is involved in risk-adjusting the quality measure "Percent of residents or patients with pressure ulcers that are new or worsened." That pressure ulcer measure affects payments and will be publicly reported on Home Health Compare beginning in January 2019.

CMS’ training, posted Dec. 20, reviews topics based on questions from provider trainings between November 2015 and August 2016 about Section GG. A portion of the training walks home health agencies and other post-acute providers through scenarios about how to fill out GG0170C.

GG0170C includes six response options if the activity may be completed and three response options if the activity wasn’t completed. A dash also is an acceptable response but would be used rarely, in situations such as if a patient transfers or dies before the assessment occurs.

GG0170C Scenario

Ms. A’s feet do not reach the floor when sitting on her bed, so she uses a stool to both get into and out of bed. She places the stool in the appropriate place herself before climbing into bed so she can get back out later. Would the appropriate response in GG0170C be 06 or 05?

Response & Rationale: Select Response "6 – Independent" as long as the patient does all of that independently. You may find some patients who crook their foot and grab the stool — they’re really very agile — and they’re used to doing this, so they will take a foot and they will move the stool if it is close by. Sometimes they’ll grab their cane and with the end of the cane they’ll pull the stool underneath their feet in order to get their feet on the stool. If that happens, that patient is independent and they’re showing a lot of independence. So describe what they did and the reason for your answer and you’re good to go. If somebody else places that stool there or hands them a cane to use in the transfer, then Response "5 – Setup or clean-up assistance" is appropriate.

Understand when & how to use neoplasm table

Understanding how the neoplasm table works with the alphabetic index is key to ensuring that you find the right code for a patient’s cancer condition.

The alphabetic index leads you directly to codes for many specific types of cancer, or cancers that are grouped by their histologies, says Judy Adams, HCS-D, president of Adams Home Care Consulting in Durham, N.C. These would include diagnoses like melanomas, lymphomas, and carcinoid and neuroendocrine tumors.

But for neoplasms that aren’t specified by their histology and that are just generally referred to as neoplasms or cancer, the index will lead you to the neoplasm table, where neoplasms are grouped by their anatomical site (such as breast) in rows, and by their behavior (such as malignant or benign) in columns.

For example, when searching the index for "breast neoplasm," you’ll first notice the lack of codes under the listing as well as the note next to the entry for "Neoplasm" that says "See also table of neoplasms."

A neoplasm’s behavior is referring to whether it’s primary malignant, secondary malignant, in situ, benign, uncertain behavior or unspecified. A primary malignant neoplasm is a reference to the original site of the tumor, versus a secondary malignant neoplasm which is the location to which it spread from the original site. A neoplasm that’s in situ, or "in place," has not yet spread.

Simply put, a neoplasm described as "of uncertain behavior" means that a biopsy has been performed but the histology of the neoplasm couldn’t be determined, says Trish Twombly, HCS-D, senior director for DecisionHealth in Gaithersburg, Md.

This is distinct from an unspecified neoplasm, which means a preliminary diagnostic study has been performed resulting in a diagnosis of a neoplasm but a definitive study (such as a biopsy) has not yet been performed, preventing the physician from making a more specific diagnosis about the neoplasm’s behavior, Twombly says.

2018 case-mix table within final rule shows increase for pulmonary diagnoses

Home health agencies are receiving another opportunity to earn case-mix points for pulmonary diagnoses. That’s according to the new case-mix table published in the 2018 final PPS rule, which takes effect Jan. 1.

In 2017, a case-mix pulmonary diagnosis code earns only one point — and that’s only when it occurs in the late episode, high-therapy equation. But next year, these diagnoses also could be eligible for two points in the early episode, high-therapy equation.

However, the one point currently available when a pulmonary diagnosis interacts with a response of ‘1’ or more on OASIS item M1860 (Ambulation) will no longer be there after Jan. 1.

In fact, that category (line 24 of the case-mix table) was gutted of its one available point.

Meanwhile, two previously gutted categories — Neuro 3 (stroke conditions) when they interact with OASIS items M1810/1820 for dressing upper and lower body (line 16 in the table), and OASIS item M1400 capturing dyspnea (line 42) — will see points added back in certain equations.

Decreases also occur for cancer diagnoses (line 3). Instead of earning five points in the high-therapy equation, agencies will earn four.

ICD-10 Neoplasm Sequencing Tool

Use this tool, adapted from one originally created by Ann Rambusch, HCS-D, president of Rambusch3 Consulting in Georgetown, Texas, to help you properly sequence neoplasm codes.

Type of treatment guides surgically treated pressure ulcer complication coding

Code surgically treated pressure ulcers that fail as complications of either a skin or tissue transplant, from the T86.8- subcategory (Complications of other transplanted organs and tissues).

Home health agencies deal with these types of pressure ulcer treatment complications frequently so knowing how to code them is important. Skin grafts and muscle flap procedures "fail all the time," says Ann Rambusch, HCS-D, president of Rambusch3 Consulting in Georgetown, Texas.

Select the specific code based on whether the treatment involved a skin graft or a muscle flap. For example, an alphabetic index query for "complication, transplant, skin, failure" on the Home Health Coding Center leads directly to T86.821 (Skin graft (allograft) (autograft) failure).

The path to the code for a failed muscle flap is less clear given that there isn’t a specific listing for this type of complication in the index. Thus, the appropriate code choice is found in the "specified tissue NEC" option, which is T86.891 (Other transplanted tissue failure). A query on the Coding Center for "complication tissue transplant failure" will lead you directly to that code.

Be sure to also assign the code for the unstageable pressure ulcer that the skin graft or muscle flap was performed to treat as long as the graft or flap is still obscuring the wound bed, according to coding guidelines. And, note the guideline that instructs you to assign an additional code for the specific complication in addition to the T86.- code. [I.C.19.g.3.a]

If all you know is that the skin graft failed but not specifically why, T86.821 along with the code for the unstageable pressure ulcer is sufficient, says Brandi Whitemyer, HCS-D, an independent home health and hospice consultant in Canton, Ohio.

But if documentation states that the skin graft failed due to infection, for example, assign an additional code for the infection, Whitemyer says.

Tip: Code the pressure ulcer at its worst stage when a failed skin graft or muscle flap exposes the wound thus making it stageable again, Whitemyer says.

Draft CoP interpretive guidelines released

CMS’ long-awaited draft version of the interpretive guidelines for the revised Home Health Conditions of Participation (CoPs) provides agencies some clarity about what surveyors might focus on and how to avoid citations beginning Jan. 13, 2018.

Agencies should study this guidance immediately and use it to prepare for the CoPs.

Understand as well that the 85-page draft released Oct. 27 shows CMS is marching forward with plans to enforce the revised CoPs, contends Arlene Maxim, vice president of program development with Quality in Real Time (QIRT) in Floral Park, N.Y. For agencies waiting until the last minute to prepare, they better get to work.

CMS is collecting comments on the draft guidelines, and a final version is expected to be released in December.

Unfortunately, agencies will have to wait until that release to see how CMS will change the state operations manual as a result of the revised CoPs, says attorney Robert Markette of Indianapolis-based Hall, Render, Killian, Heath & Lyman. That means broader survey guidance on the revised CoPs, which would detail how survey guidelines will break down into level 1 and level 2 standards, isn’t currently available to view.

2018 final PPS rule’s effect on HHAs by region

Agencies in the Pacific region will see a payment increase of 0.6% in 2018, the best deal under CMS’ policies. Meanwhile, agencies in the East South Central region will see the biggest reduction, -1.6%.

Note: CMS will decrease payments for rural providers by 2.5% and decrease payments for urban providers by 0.1%.

Improve your HHCAHPS scores by better informing patients about arrival times

By keeping patients better informed about when clinicians will arrive, agencies can improve their performance on two low-scoring HHCAHPS questions. Such an improvement could raise your agency’s HHCAHPS results and star rating, something referral sources strongly consider.

According to data from Strategic Healthcare Programs (SHP) in Santa Barbara, Calif., the third-lowest scoring HHCAHPS question is, "When you contacted agency’s office, how long did it take to get the help/advice needed?"

The sixth-lowest scoring question is, "In the last two months of care, how often did home health providers from this agency keep you informed about when they would arrive at your home?"

Agencies earned the highest possible scores on these questions 77.3% and 80.3% of the time during the 12-month period ending in March 2017, SHP data show.

The two issues are linked because the concern patients most commonly call agencies about involves what time the clinician will come to their home, contends Gina Mazza, a partner at Fazzi Associates.

One major issue with poor responsiveness to patients occurs because many agencies rely heavily on using voicemail rather than answering all calls, Mazza notes.

Patients and their families should never be funneled into voicemail via a phone tree, she argues. "If someone has a question, they should be going to someone that has an answer," Mazza says.

The problem with relying on voicemail is that, for example, an employee might check messages several times in the morning but the patient might call in the afternoon and not hear back until the next day. The way the associated HHCAHPS question is crafted, agencies earn the top score by providing help/advice the same day the patient contacts the agency’s office.

To boost your HHCAHPS score on Question 15, which examines keeping patients informed about what time clinicians would arrive:

• Confirm your visit in advance
• Give patients a range of when you’ll arrive
• Update the patient if the clinician will arrive outside of the range – either late OR early

Majority of new case-mix additions come from FY2018 update

All but one of the 79 codes that are newly eligible for case-mix status – effective Oct. 1, 2017 – are brand-new to the ICD-10 code set, arriving in the FY2018 update.

Among them are the additions to the L97.- category that describe non-pressure ulcers that have gone into muscle and bone tissue but haven’t caused necrosis, according to the newest release of the grouper (v6217) posted July 24.

In total, 79 codes have been added to the case-mix list and 16 codes lost case-mix status. The list of codes eligible for non-routine supply (NRS) points increased by 67, also effective Oct. 1.

Additional new codes that gained case-mix status on Oct. 1 include those for an unspecified heart attack (I21.9), all nine of the new heart failure codes from the newly created I50.8 subcategory (Other heart failure), one of the new codes for type 2 diabetes with ketoacidosis (E11.10), the new codes for Clostridium difficile (A04.7-), and the new codes for spinal stenosis that occurs with (M48.062) and without neurogenic claudication (M48.061).

The codes from the L97.- category that lost case-mix status on Oct. 1 are from the L97.50- (Non-pressure chronic ulcer of other part of unspecified foot) and L97.80- (Non-pressure chronic ulcer of other part of unspecified lower leg) subcategories that capture non-pressure chronic ulcers that don’t specify laterality.

Also note, most of the new L97.- and L98.- codes also now are eligible for NRS points. effective Oct. 1. In fact, all of the codes that were newly added to the NRS list were from those two categories.

Five lowest scoring questions on HHCAHPS survey

These five questions earned the lowest scores from April 2016 through March 2017 on the HHCAHPS survey, according to data from the Strategic Healthcare Programs (SHP) in Santa Barbara, Calif. The survey asks 34 questions and SHP’s data represent about 540,000 surveys completed.

Reduce 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.

FY2018 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.

Average 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.

How 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]

New 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.

Sample 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.

Carefully 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.

New 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.

Featured 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.

Final 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.

Training 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.

Featured 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.

Agencies 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.

Hospice 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.

Featured 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.

Get 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.

Stay 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.

Featured 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.

Use 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.

CMS 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.

Featured 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.

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!

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Look 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.

Election 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.

Featured 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.

Use 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.

CMS 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.

Featured 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.

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.

Supervisory 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.

CMS 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.

Featured 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

Learn 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.

FY2017 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.

Featured 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.

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.

Hospice 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.

Code 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.

Featured 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.

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!

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!

Learn More

Coding 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.

CMS 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.

Featured 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.

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.

NPUAP 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.

Revised 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 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:

ICD-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.

Expect 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.

Featured 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

• Click here for the answer

  D. None of the above
  F02.80 is a manifestation code, meaning it cannot be listed as a principal diagnosis. Manifestation codes can be reported only when sequenced after its underlying etiology code. Some examples of etiology codes that might be sequenced before F02.80 are Alzheimer’s disease (G30.-), Epilepsy and recurrent seizures (G40.-), Multiple Sclerosis (G35) and Parkinson’s disease (G20).

  CMS began returning to provider (RTP’ing) hospice claims with vague diagnoses such as adult failure to thrive and debility (e.g., R53.81) as the principal diagnosis beginning in October 2014. In cases where it is difficult to determine from the documentation which one single diagnosis is the primary reason for the patient’s terminal condition, your hospice’s interdisciplinary group (IDG) should determine which of the diagnoses is the most contributory to the terminal prognosis.

  Z codes, which identify “factors influencing health status and contact with health services”, should not be used as principal diagnoses on hospice claims.

Coding 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.

Prepare 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
  
  

Scenario: 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:

• 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.

Agencies 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:

MAC 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.

Featured 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.

Combination 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.

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.
  
  

OASIS-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:

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.

Scenario: 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:

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).