Home Health & Hospice Week

Lots of new coding options available under proposed PPS refinements.

Case mix diagnosis groups are getting an extreme makeover. Get ready to toss your old cheat sheets and give your coding practices an update.

The Centers for Medicare & Medicaid Services' proposed rule on the prospective payment system released April 27 not only expands diagnoses in the existing case mix diagnosis groups, it more multiplies the number of groups five-fold.

Instead of the current four case mix diagnosis groups (neurological, orthopedic, diabetes and burns and trauma), the rule proposes to expand and break diagnoses out into 20 new groups.

The changes "are definitely more reflective of home health services than the original four case mix groups," says consultant Judy Adams with Larson-Allen in Charlotte, NC. "Now, more than ever, coders will need to pay close attention to sequencing diagnoses."

One benefit of the expanded case mix groups will be less pressure to use one of the diagnoses in the original limited group, Adams says.

Getting serious: The new case mix groups will reduce gaming and upcoding, predicts consultant Lisa Selman-Holman of Selman-Holman & Associates in Denton, TX. Coders who make their diagnosis code selections based on the focus of the care and also code the co-morbidities will get the number of points intended she says.

It will be very difficult to selectively choose codes to get the best reimbursement, Selman-Holman says. This is because there are now four equations, which determine reimbursement, depending on the number of therapy visits the patient will receive and which episode (early or late) the patient is in. One coding combination in the first episode may get you a certain number of points and the same coding combo in the third episode may not get you any points, she says. Secondary Diagnoses Take Center Stage In developing the new groups, CMS added secondary diagnoses to the case mix system. This change in calculation is an effort to account for the cost-increasing effects of comorbidities, CMS says.

However, assigning scores to both primary and secondary diagnoses could lead to redundancies, so CMS proposes to recognize only the primary diagnosis in episodes where both primary and secondary diagnoses from the same diagnosis group are listed.

"Recognizing the primary diagnosis, but not the secondary diagnosis in the same diagnosis group, seems like a reasonable approach to using the variable system," says Adams. When used correctly, the new system should recognize the impact on case mix for key diagnoses, yet not overstate the impact when there are multiple diagnoses from the same group, she says.

Bonus: Most coders know there are conditions they should always code because these conditions may affect the care, even if they are not the focus of care, Selman-Holman says. Some [...]