Home Health ICD-9/ICD-10 Alert

Published on Sat Oct 23, 2004 PDF

Warning: Haste or ignorance can look like fraud.

If you find 716 codes showing up often in M0230 or M0245, you may want to question your coding accuracy - before your payer starts questioning you.

Patients often receive home care following a joint replacement or other treatment for arthritis, experts say. But coding the arthritis seems to be a hit-or-miss affair for home health agencies.

"I've seen lots of agencies use 716 diagnosis codes for arthritis when they should have used 715 codes," says Laresa Boyle director of coding services at Longview, TX-based Healthcarefirst. This slight difference may seem like a minor concern until you realize that the 716 codes are case mix codes that can add extra reimbursement to an episode, while the 715 codes are not. (See Article 5) The 11 points you receive for the case mix code can translate into hundreds of dollars extra for that episode - which makes using that code great if you deserve it, but dangerous if you don't.

Don't jump to conclusions: People typically think of arthritis as an inflammatory condition of the joints, characterized by pain, redness, heat and swelling resulting from inflammation, infection or trauma. But osteoarthritis - also known as osteoarthrosis or degenerative joint disease - is a non-inflammatory progressive joint disorder characterized by degeneration of the cartilage, hypertrophy of bone at the margins and changes in the synovial membrane, Boyle explains.

The most common form of arthritis is osteoarthritis, Boyle reminds providers. This condition affects more than 80 percent of those who reach the age of 70, research shows. And 715.xx (Osteoarthritis and allied disorders) specifically addresses this diagnosis.

Home health agencies should never make assumptions about a patient's diagnosis, says Sue Prophet with the American Health Information Management Association. Rely on physician documentation when coding for a patient or risk having the intermediary downcode your claim.

As HHAs learn to be more careful in their coding, they are making fewer arthritis coding errors, reports consultant Pat Sevast with American Express Tax & Business Services in Timonium, MD. The first step toward bulletproof coding is understanding how to use the coding manual.

Avoid this common mistake: Errors in arthritis coding can result from using only the index and stopping when you find a likely code, experts say. For example, say you know the patient has arthritis. If you go to the index of diseases in the coding manual and look up arthritis, you see: Arthritis, arthritic (acute) (chronic) (subacute), 716.9x. If you stop there and don't read the next section, you miss the directions to go to the osteoarthritis entry, if that's the kind of arthritis you mean. That entry directs you to 715.9x.

Even if you stop with 716.9x, as long as you remember to check your code choice in the tabular list section of your manual, you'll have another chance to get it right. Code 716 (Other and unspecified arthropathies) and its subcategory 716.9x (Arthropathy, unspecified) should also prompt you to ask more questions, experts agree.

"Remember, code to the highest level of specificity," Sevast warns. 716 is an unspecified code. If you can't find more specific information, you can use the less specific code, but make the choice consciously - not out of ignorance, experts say.