Home Health ICD-9/ICD-10 Alert

Published on Sun Jan 01, 2006 PDF

Reporting diabetes in M0245 will give your agency 17 case mix points.

If you code diabetes as primary in two successive episodes, you may be sending up a red flag for your intermediary.

List diabetes as the primary diagnosis on your claim and your agency will receive additional reimbursement because diabetes is a case mix diagnosis. But to code diabetes as primary, the plan of care must be focused on managing the diabetes care or a diabetic manifestation or you risk a denial. 

Check the clinical notes when coding for a diabetic patient, advises Judy Adams RN, BSN, HCS-D with Charlotte, NC-based LarsonAllen Health Care Group. "Clinicians can use the acuity codes on the OASIS to help select the order of diagnoses," she says, "The diagnosis with the highest severity/acuity would be the primary reason for the home health services."

Don't Risk Denials For Second Episodes

Your intrermediary may deny your claim when diabetes was coded as a primary diagnosis in the first episode, and then carried over as the primary diagnosis for the second episode of care. Make certain your coding addresses the reason you are seeing the patient during this episode of care and what skilled services you will provide, advises Adams.

Example: During the first episode of care, a patient with diabetes and congestive heart failure (CHF) is taught about his recent diabetes diagnosis and instructed on care and monitoring of this new condition as well as monitoring his cardio-pulmonary status related to the CHF. For this episode, you would use 250.00 (Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled) in M0230 and 428.0 (Congestive heart failure, unspecified) in M0240, says Adams.
 
At reassessment for the second episode, the patient is doing well with care and monitoring of his diabetes. But, he has experienced some increased lower extremity edema and weight gain. The HHA is asked to continue monitoring his cardio-respiratory status, weight, and the diabetes. Correct coding for this episode would list 428.0 in M0230 and 250.00 in M0240, "since the focus has shifted to CHF as the highest acuity diagnosis and the diabetes is relatively stable," says Adams.  
 
Mistake: Are you tempted to code diabetes as primary when the focus of the care is a pressure ulcer? Pressure ulcers are not manifestations of diabetes, experts warn. If a pressure ulcer is the focus of care, then you should code for it in M0230 and list the diabetes as a secondary diagnosis.  

Depending on the situation, if you're providing care to a diabetic patient and reporting a V code in M0230, you may want to include the diabetes case mix code in M0245 as your payment diagnosis code. This will net your agency 17 case mix points on the claim.
  
Example: You are providing dressing changes for a patient following the amputation of a toe. Your patient is diabetic and has had the toe amputation due to gangrene. The gangrene is the result of the peripheral vascular disease secondary to diabetes. Dio Namocatcat with the Visiting Nurse Regional Health Care System in Brooklyn, NY suggests coding as follows:

M0230a: V58.49 (Other specified aftercare following surgery);
M0240b: 250.7x (Diabetes with peripheral circulatory disorders);
M0240c: 443.81 (Peripheral angiopathy in diseases classified elsewhere) ;  
M0240d: V58.3 (Attention to surgical dressings and sutures);
M0240e: V49.72 (Lower limb amputation status, other toe[s]);   
M0245a: 250.7x (Diabetes with peripheral circulatory disorders);
M0245b: 785.4 (Gangrene). 
    
Note: If a diabetic patient has gangrene, coding guidelines assume the gangrene to be a manifestation of the diabetes unless the physician otherwise specifies.