Home Health ICD-9/ICD-10 Alert

Published on Sat Jan 26, 2008 PDF

V codes and manifestation codes may not work the way you think.

If you're looking for all your prospective payment system information in the final rule, you'll miss vital details that could impact your bottom line.

Old way: Under the old PPS, any V code in M0230 could trigger the case mix system to consider a diagnosis code from M0245 toward case mix.

New way: Under the PPS refinements now in effect, only 25 V codes or code categories will trigger a possible M0246 payment.

The grouper "must be looking at a complete and appropriate V code before looking at M0246," explained Henry Goldberg of Abt Associates at the OASIS Certificate and Competency Board's annual conference in Baltimore Nov. 12.

The Centers for Medicare & Medicaid (CMS) lists the eligible V codes in the grouper pseudocode, Goldberg explains to Eli. The new PPS system will accept only V codes from that chart for payment purposes, said Goldberg at the conference which drew about 170 attendees.

Abt is the Centers for Medicare & Medi-caid Services' contractor on a number of projects including PPS and pay for performance (P4P). OCCB administers COS-C credentialing and is CMS' contractor on certain OASIS issues.

"This information is not in the final rule," stressed OCCB's Linda Krulish at the session. Instead, home health agencies must wade through the grouper and pseudocode to ferret out this information. "It's extra stuff added to the final rule," noted Krulish.

Caution: If you fail to realize which V codes cause M0246 codes to count, you could think you have more money coming to you when you don't.

And you must realize that for the M0246 code to count toward payment, it must be in the same coding line as the V code that triggers it, Goldberg said.

Advice: Don't try to memorize these V codes, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Hol-man & Associates in Denton, TX. Instead, follow the OASIS instructions and place the case mix diagnosis in M0246 across from the V code regardless of whether the V code is on "the list."

The grouper won't count the case mix diagnosis if it is placed across from a V code not on the list so you're not cheating, Selman-Holman says. The PPS Refinement is very complex, and if you try to distinguish your use of M0246 by whether you are going to get points or not, you're going to make your job more difficult.

Another area that was not covered in the final rule is etiology codes for manifestation codes, Gold-berg noted.

Of the roughly 1,290 diagnosis codes that now count as case mix codes, 184 are manifestation codes, Goldberg explained. ICD-9 coding rules don't allow coders to use manifestation codes first. Instead, those codes must be listed following a main etiology code.

Old way: Previously, PPS didn't check what code a manifestation code followed.

New way: Under the refinements, the PPS grouper won't recognize a manifestation code "unless it's directly following an appropriate and complete etiology code," Goldberg emphasized.

Example: The manifestation code 336.2 (Subacute combined degeneration of spinal cord in diseases classified elsewhere) gains case mix points only if certain etiologies precede the code in sequencing, such as 266.2 (B-complex deficiency NEC), 281.0 (Pernicious anemia) and 281.1 (B12 deficiency anemia NEC). If the code is not preceded by one of the acceptable etiologies, there will be no points for 336.2.

Additionally, when both the etiology and the manifestation are case mix codes, the grouper will award the points for the highest score. For example, if the patient has 281.1 (B12 deficiency anemia, NEC) causing the degeneration of the spinal cord, there will be points awarded for the degeneration in Equation 1 (but only if the patient also has a toileting score of 2 or more) but no points for the anemia. In later episodes, points are only possible from the degeneration, not the anemia.

Your bottom line: This could be a reimbursement drain if agencies fail to correctly pair manifestation codes with the appropriate etiology codes, experts caution.

Note: The grouper and pseudocode are available at http://www.cms.hhs.gov/center/hha.asp.

For more on the PPS refinements beyond coding and how they will impact your agency, see Eli's Home Care Week at http://www.elihealthcare.com/spec_home_care.htm.