Home Health Blogger

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

Posted by Melissa Cott on May 6, 2020

With CMS’s Home Health Patient Driven Groupings Model (PDGM) that became effective 1/1/2020, the practice of coding home health OASIS assessments also changed. Before, we recorded six (6) diagnosis codes on the OASIS assessment. Now, we can include up to twenty-five (25) diagnoses on the OASIS assessment.

The purpose of expanding the number of diagnoses was to give the home health agency (HHA) the opportunity to report co-morbidities and risk factors that affect patient care, the possible need for more services and with it, necessary additional reimbursement. As long as your selection of diagnoses is supported by the physician face-to-face documentation, discharge documentation from the hospital or physician’s office, you can code these diagnoses in your OASIS assessment. ICD 10

Do's of Coding under PDGM

1. Align OASIS ICDs with Referral Documentation from the Physician

Medicare regulations require that a physician, with a current and active physician license, must order home health care services. The HHA must obtain written documentation of the physician’s home health care order. The order can be documented by the physician in several ways: Discharge Summary, Referral, Patient Assessment, History and Physical, Physician Progress report. The written summary may or may not actually contain the diagnoses codes you will use on the OASIS assessment. If the document does not have the actual ICD-10-CM code, you must select the most appropriate code from the ICD-10-CM list. If the report has the actual diagnosis codes, you’ll use those codes.

How to Select the Primary DiagnosisDownload PDGM Diagnosis Coding Guide

The primary reason for home care, i.e. OASIS item M1021, is always the primary diagnosis. The physician who signs the plan of care (CMS485), i.e. the ‘certifying’ physician (as opposed to the ‘referring’ physician’) always determines the primary diagnosis and documents this during the face-to-face encounter required by Medicare.

What is the Physician Face-To-Face Encounter?

The ‘physician face-to-face’ is a Medicare regulation required for initiating home health services. It is NOT required for recertification.

As required by Medicare, within 90 days prior to or within 30 days after the start of care date, the certifying physician must provide a document that includes a description how the patient’s clinical condition, as seen during that specific face-to-face encounter, supports the patient’s homebound status and need for skilled services. The ‘face-to-face’ MAY or may NOT be included in the written referral documentation as described above.

A suitable ICD-10-CM diagnosis code may or may not be included in the face-to-face narrative. If a diagnosis code is NOT included in the narrative, the HHA must select the code that best represents the description of the problem provided in the narrative. If the physician includes the code, the ICD code will be used on M1021. The face-to-face encounter documentation is only required for the initial certification.

2. The primary diagnosis must have a Patient Driven Groupings Model (PDGM) classification.

The primary diagnosis must have one of twelve PDGM classifications according to home health care coding guidelines. Of the more than 70,000 ICD-10-CM diagnosis Codes, about 43,000 have PDGM classifications and can be used as a primary diagnosis. Click here to access the list of ICD-10-CM Diagnosis codes that have a PDGM classification.

If the Primary Diagnosis Does Not Have a PDGM Classification….

The HHA must consult with the physician to identify a suitable replacement that meets this requirement.

Don'ts of Coding under PDGM

Don't code ICDs that can't be supported by the physician's referral documentation.

Just in case the patient's chart is audited by Medicare, you want to make sure that all diagnoses are verifiable by the physician or hospital referral. 

PDGM Home Health Billing: Significant Change in Condition (SCIC)

COPD Patient Teaching