Home Health ICD-9/ICD-10 Alert

Published on Thu Sep 27, 2007 PDF

Here's how to accumulate case mix points in 2008.

Checking Table 2A under the new PPS final rule helps you be sure you get the reimbursement you deserve.

When the payment diagnosis shifts from M0245 to M0246 on Jan. 1, the process of getting case mix payment for a home care episode becomes much more complicated. If you place a V code in the primary or any of the secondary diagnosis positions in M0230 and M0240 -- and the V code replaced a case mix diagnosis -- you have an opportunity to gain case mix points for the episode.

Besides putting the case mix diagnosis in M0246, you also need to determine if the code the V code replaced "achieves case mix status" for reimbursement, says consultant and coding specialist Tricia Twombly, BSN, RN, HCS-D, with Foundation Management Services in Denton, TX.

Just as you use a specific sequence of steps to get a math problem correct, you need to accept that Table 2A (see pp. 76-77) follows Table 2B in the case mix calculation. Once you place a V code in M0230/M0240, begin this analysis, or you may be leaving money on the table.

After Jan. 1, getting the case mix answer will be a five-step process, Twombly says. Start with this example, she suggests:

Scenario: You admit a patient who has difficulty swallowing due to a stroke. The physician orders speech therapy, and the therapist expects to see the patient six times. The patient has never been seen in a home health setting prior to this admission.

Step 1: Decide how to code the claim. The primary reason for home care is speech therapy for dysphagia secondary to a stroke, so you code V57.3 (Speech therapy).

Step 2: Determine what underlying diagnosis the V code replaced. Because the dysphagia is secondary to a stroke, the underlying diagnosis would be 438.82 (Late effects of CVA with dysphagia).

Heads up: Beginning Oct.1, new coding instructions for 438.82 will indicate to use an additional code to specify the phase of swallowing affected -- 787.2x.

Step 3: Consult the list of new case mix codes for 2008. The final PPS refinement rule includes a multi-page list (Table 2B -- Diagnosis Codes) of all the potential case mix codes for 2008. "So get out Table 2B to determine if the underlying diagnosis to the V code made the list," Twombly says.

Our scenario: When you look through Table 2B, you find that 438.82 is a case mix code from the Neuro 3 category. This code goes in M0246.

Step 4: Check for variables in Table 2A. Under the new rules for 2008, this is an early episode with low therapy use expected. Table 2A, line item 15, refers to "Neuro 3 -- Stroke" and indicates that a CVA code can achieve case mix payment status independent of other variables if it is an early episode with high therapy, Twombly explains. This rule excludes our scenario from accumulating case mix points unless it fits within another variable.

Other line items in the table also refer to Neuro 3 -- Stroke. Line item 16 allows case mix points for the stroke diagnosis combined with difficulty dressing the upper or lower body. Line item 17 allows case mix points for strokes in early episodes with significant ambulation problems.

Our scenario: And line item 6 allows case mix points for a combination of stroke and dysphagia. "If a code is used from the Neuro 3 category and the patient has dysphagia, the code for dysphagia (787.2x) is available for case mix points in early episodes with low or high therapy," Twombly explains.

Step 5: Check the record. The last step is to check the clinical record and the pertinent OASIS response to be sure they support your coding choices, Twombly reminds coders.

Tip: Each line item in the table is a chance for case mix points and points are cumulative, Twombly says.