Home Health Blogger

Home Health Coding: Medicare Do's & Don'ts

Posted by Melissa Cott on Mar 26, 2015

The practice of home health coding can be subjective.  Medicare has guidelines, however, on how home health agencies select diagnosis codes for the OASIS assessment.4883994

The following are key points when determining diagnosis codes for OASIS.  The full CMS Diagnosis coding guidelines are published here: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/downloads/hhqiattachmentd.pdf

OASIS Integrity

  • Avoid the practice of allowing the case mix status of a diagnosis to influence the diagnosis selection process, also known as ‘upcoding’.
  • HHAs are expected to prevent “upcoding” from occurring.
  • HHAs are expected to report any indication of upcoding directly to the administrator of the HHA.
  • If appropriate action is not taken by Administration, then the clinician is expected to report this activity to the appropriate RHHI hotline and/or to the State Surveyor hotline.

Comprehensive assessment must precede diagnosis coding…

  • HHAs are expected to understand the patient’s specific clinical status before selecting and assigning the diagnosis.
  • Each patient’s overall medical condition and care needs must be comprehensively assessed before the HHA selects and assigns the OASIS diagnoses.
  • CMS expects HHAs to complete the patient’s comprehensive assessment before assigning the home health diagnoses

General Diagnosis Coding Principles

  • Code only those diagnoses which are unresolved. If a patient has a resolved condition which has no impact on the patient’s current plan of care, then the condition does not meet the criteria for a home health diagnosis, and should not be coded. 
    • Example: if a patient has Hypertension and the status is stable, don’t include Hypertension in the coding profile.
  • Avoid assigning excessive numbers of V-codes to OASIS M1020/1022.
    • A V-Code is considered a code of ‘last resort’. CMS expects HHAs to limit the reporting of V-Codes on the OASIS. 
    • V-codes are less specific to the clinical condition of the patient than are numeric diagnosis codes.
  • Code only the relevant medical diagnoses. For example, if a patient is admitted for surgical aftercare (e.g., the surgery eliminated the disease or the acute phase has ended), the acute diagnosis should not be coded in M1020/M1022.
    • Example: Instead of “Cerebral thrombosis without mention of cerebral infarction 434.00” use “Late effects of cerebrovascular disease 438.89”.
  • Code only the diagnoses supported by the patient’s medical record documentation (i.e., the home health plan of care and clinical comprehensive assessment).
  • If the diagnosis under consideration is not supported by the patient’s medical condition and clinical care needs, then the diagnosis must not be reported on the OASIS.
  • If a diagnosis does not have medical treatment prescribed (medications) or evidence of the diagnosis in the comprehensive assessment, don’t include it.

Avoid selecting a diagnosis with the following characteristics for assignment to the OASIS:

  • Non-specific or ambiguous diagnosis: Pain in limb 729.5
  • Symptom diagnosis (general symptomatic complaint in the elderly population): Muscle weakness (generalized) 728.87
  • Surgical procedures

When selecting a primary diagnosis...

  • Ensure that of all the diagnoses under consideration for this patient, this is the diagnosis requiring the most intensive skilled services.
  • If more than one diagnosis is treated concurrently, the diagnosis that represents the most acute condition and requires the most intensive services should be assigned to M1020 of the OASIS.
  • Ensure that of all the diagnoses under consider-ation for this patient, this is the diagnosis requiring the most intensive skilled services.
  • If more than one diagnosis is treated concurrently, the diagnosis that represents the most acute condition and requires the most intensive services should be assigned to M1020 of the OASIS

When selecting other diagnoses...

  • Other diagnoses are defined as all conditions that coexisted with the primary diagnosis at the time the plan of care was established, or which developed subsequently, and that affect the treatment or care.
  • Ensure that the secondary diagnoses assigned to the OASIS are listed in the order to best reflect the seriousness of the patient’s condition and to justify the disciplines and services provided.

Download the Complete Home Health Billing Guide

I'm Interested in Overnight Coding Services