Complexity of home health coding dwarfs hospital issues
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A little more than 10 years ago in home health (HH), an agency could code as it wanted, with few restrictions, and get reimbursed at a high rate with no annual patient cap. Coding didn't matter, according to many, because there wasn't stringent regulation surrounding it. It was a time of PAIN-FREE CODINGTM.
HH has had significant regulatory changes over the past decade and half:
- IPS, which gave a per patient per year reimbursement cap, came and went, forcing many agencies to close
- PPS 2000, began the era of specific documentation, the case-mix system and many other regulations
- OASIS assessment in 2002 brought the first standard data gathering
- V codes became required use in 2003, increasing the complexity of coding in order to receive proper payment
- PPS 2008 radically altered case-mix and therapy, and linked coding and OASIS more closely
- OASIS-C in 2010 brought a more specific data tool with more coding links
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Consider this coding example: A patient is admitted to the hospital with a break at the neck of the femur due to a fall. She has a total hip replacement as an inpatient. The patient has type II diabetes for which she takes insulin and has hypertensive chronic kidney disease, stage 4. She also has CAD, hypothyroidism, chronic COPD and hyperlipidemia. While in the hospital she had a COPD exacerbation, and the exacerbation is ongoing. She is admitted to home health for aftercare of surgery.
For hospital coding purposes, a coder, in any order, would code these eight diagnoses AND get reimbursement for them: 820.8, femur fracture; 496, COPD; 250.40, diabetes with renal manifestations; 414.00, CAD unspecified; 403.90, stage 4 hypertensive kidney disorder; 585.9, chronic kidney disease; 272.4, hyperlipidemia, NOS; 244.9, Hypothyroidism, NOS
For procedures, code 81.51 for the total hip replacement.
HH coders must prioritize the codes according to the amount of skill needed over the 60-day admission, and must include extra status V codes (that might not be reimbursable) AND will only potentially be paid for the first six diagnoses (of 11 codes, not eight), IF they are reimbursement-eligible. These coders must pore through hospital records for information and must work with clinicians to ensure the correct listing of diagnoses according to the level of skilled care given.
These codes should be placed in the payment slots (M1020, M1022) prioritized by the level of skilled care provided: V54.81 Surgery aftercare code, which is not eligible for revenue but because it is the reason for admission, it must be coded. (820.8, diagnosis of the femur, is coded in a special slot to potentially gain revenue. Fractures cannot be coded in M1020 or M1022 slots.); 491.21, COPD with acute exacerbation; 250.40, diabetes with renal manifestations; 403.90, stage 4 hypertensive kidney disorder; 585.9, chronic kidney disease; 414.00, CAD unspecified.
Codes in nonpayment slots: 272.4, hyperlipidemia, NOS; 244.9, Hypothyroidism, NOS; V58.67, long-term use of insulin; V43.64, hip replacement; V15.88, history of falls
Procedure code 81.51 for the total hip replacement must also be coded in the home health record.
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Today, HH requires precise medical coding to comply with federal rules and regulations and to ensure proper revenue is received.Daymarck has watched as HH coding has grown in complexity. Today, you will rarely hear that coding doesn’t matter, but you find that in home health agencies affiliated with hospitals, there isn’t a clear understanding that HH coding is specialized and unique. The coding example shows the importance of ranking diagnoses by skilled care, and illustrates that HH coders must refer to clinicians and records to code correctly. Improper coding in this scenario can lead to under payment between $250 to $350, dependent on how other OASIS questions are answered.
Below are some of the major issues that distinguish HH coding from hospital coding:
- HH and Hospital have different reimbursement systems. HH is the only setting where you are eligible for reimbursement on a tiered level, and only for some diagnoses: just six per patient. The “bonus revenue” codes in home health do not correspond to DRGs. In the example on the previous page, home health must code more and will be eligible for revenue on fewer codes. In HH, diagnosis coding can affect overall reimbursement, supply reimbursement and risk adjustment on quality outcomes. Because the difference in reimbursement and regulation are so great, CMS has a separate hospital reimbursement policy, advisories, and regulations from its HH reimbursement policy, advisories, and regulations.
- HH must gather information for coding from multiple referral sources.As a result, HH coders must be familiar with inpatient procedure codes, late effect codes, and know how to read discharge information, rehab reports, and more.
- A HH “admission” and plan of care run over 60 days, and adjustments must be submitted if the plan changes.It covers the work of nursing, PT, OT, and SLP. Records are coded as you go in HH, versus post-admission coding at hospitals. In the example above, a coder lists diagnoses based on the skilled care provided over the 60 days, not by order of care or severity of disease or in a random pattern.
- Hospital and HH coders must know ICD-9 procedure and diagnosis coding.HH coders are responsible for coding acute and post acute diagnosis. Hospital coders only code acute diagnosis. There are many compliance regulations that dictate restrictions on HH in these areas. In the example above, fractures cannot be coded in active diagnoses slots in HH; it’s a restriction imposed through post-acute regulations. A V-code must be used, however, to receive proper payment and maintain compliance. The fracture code needs to be coded in the corresponding case-mix diagnosis slot. There is no such coding concept in hospital coding.
- HH coders often work directly with clinicians and at times a multidisciplinary team. Because they gather information from home visits, they must clarify a patient’s symptoms or the clinician’s evaluation to code correctly.
As the health care sector anticipates massive regulatory changes over the next few years, including bundling of care or the relaxation of homebound status as a requirement for home visits, the versatility of home health coders will become more obvious.
It should be clear to any hospital system with an affiliated home health agency that the home health coders within the system must be specialized and knowledgeable beyond the acute coding arena.
It should also be clear to the administration of stand-alone agencies that their coders are specialists.
The complexity of the future is already built into the home health coding system, unlike the hospital systems, which has a complex reimbursement system on the backend but is far more straightforward in its coding needs and requirements. Before the crush of changes is upon all of health care, home health agencies, stand-alone or otherwise affiliated, should be sure to have home health specialist coders affiliated with their agencies ….NOW.
Nick Dobrzelecki is the founder and CEO of Daymarck, a home health coding company dedicated exclusively to providing accurate and compliant medical coding services and consulting. Victoria Forlini is Daymarck’s Agency Development Manager and the former executive director of the Board of Medical Specialty Coding.
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