Home Health ICD-9/ICD-10 Alert

Published on Sun Apr 24, 2011 PDF

The original SOC isn't always the last word in coding.

To see how diagnosis coding impacts NRS points, consider the following scenario from Jan McLain, RN, BS, LNC, HCS-D, COS-C, with Adventist Health System Home Care in Port Charlotte, Fla.:

Meet the patient: Mrs. Hicks is an 86 year old female. She is being admitted to home health for physical therapy only, after a total hip revision to repair a fracture from a fall at home. She has hypertension that is well controlled. During the assessment visit, the therapist documents that the incision line from her hip revision is slightly separated and red, with a small amount of purulent drainage. The therapist scores the surgical wound as not healing (M1342 = 3) on the start of care (SOC) OASIS. She gives the report to the physician and obtains additional orders for three therapy visits a week for three weeks. She also gets a skilled nursing order for a skin/wound assessment.

What the nurse did: A nurse from the agency is available, so she does her visit that same day and documents a tunnel at the site of the incision separation with a moderate amount of purulent drainage, two Stage 2 pressure ulcers on the coccyx, and a skin lesion-scar on the other hip. The patient tells her she was on bed rest for an extended amount of time five years ago following a severe auto accident. As a result, she developed a "sore" on her hip that went "clear to the bone."

The nurse calls the physician, who gives orders for skilled nursing three times a week for six weeks, oral antibiotics, and wound care instructions for the infected surgical wound and the two Stage 2 pressure ulcers. She also confirms that Mrs. Hicks did have a Stage 4 pressure ulcer in the past but it is now closed. The nurse initiates treatment, completes her visit and a SOC OASIS.

Compare the assessments: When the clinical supervisor reviews the admission, there are 2 SOC OASIS assessments for Mrs. Hicks. All M items are scored the same except for the pressure ulcer items which were completed by the nurse. The diagnoses listed by the respective clinicians for this patient are as follows in the chart on page 26.

Note: There is no requirement for a second OASIS to be done in this situation. The therapist could have completed the OASIS at start of care -- the need for nursing does not mean a second OASIS should be completed. However, the two OASIS assessments in the example scenario allow for a comparison that illustrates how diagnosis coding and OASIS completion can impact nonroutine supply points.

The result: With the additional information gathered by the nurse, the focus of care for this patient changes from physical therapy to care for the postoperative infection. Therapy will still provide care for the patient, but the patient's infected wounds and pressure ulcers require greater resources.

• Line 13 = M1020a = Primary diagnosis is a postoperative complication: 23 points
• Line 23 = M1308 = 2 Pressure Ulcers, Stage 2: 22 points
• Line 30 = M1308 = Pressure Ulcer, closed, stage 4: 48 points
• Line 42 = M1342 = 3 (Status of most problematic surgical wound: not healing): 14 points

Total NRS score 107 = NRS 6

The physical therapy SOC OASIS, however, yields a much smaller number of NRS points, McLain says:

• Line 42 = M1342 = 3 (Status of most problematicsurgical wound: not healing): 14 points

Total NRS score 14 = NRS 2

Bottom line: The difference in supply reimbursement between the example SOC OASIS assessments is over $500, McLain says.

Lesson learned: The greater the detail gathered duringthe assessment, the more accurate your coding can be. Taking note of this additional information can have a positive impact on the NRS points your agency earns, and on your bottom line.