Home Health ICD-9/ICD-10 Alert

Published on Fri Sep 23, 2011 PDF

Use of 401.9 more than doubled in last five years.

It's time to prepare for a big change in how you're reimbursed for your patients with hypertension. The Centers for Medicare & Medicaid Services plans to scrap two hypertension codes from the home health prospective payment system case mix model in 2012.

From 2005 to 2009, use of 401.9 (Essential hypertension, unspecified) increased from 27 percent of episodes to 56 percent, CMS notes in the 2012 PPS proposed rule published in the July 12 Federal Register. In the same time period, the other code proposed for reduction, 401.1 (Benign essential hypertension), increased only from 2.89 to 2.95 percent of episodes.

Reason: Probably due to the widespread use of these codes, "current data indicates that these diagnoses are not predictors of higher home health patient resource costs," CMS says in the rule. "Rather, current data indicates a lower cost associated with home health patients when these codes are reported."

Other hypertension codes saw big jumps as well. For example, use of the code for hypertensive renal disease (403.x) went from 0.31 percent of episodes in 2005 to 3.66 percent of episodes in 2009, the rule says. But perhaps that code still predicted resource use, observers speculate.

Removing the two codes, which CMS also proposed last year, will be budget neutral overall, CMS says. "The revisions of the case-mix weights would redistribute HH PPS payments among the case-mix groups such that removal of these hypertension codes would not result in lower aggregate payments."

But depending on how you code your patients, it could affect your reimbursement rate disproportionately, experts point out.

While there isn't much home health agencies can do to prevent this change, don't lose all hope of garnering case mix points for hypertension diagnoses.

While CMS proposes eliminating case mix points for hypertension diagnoses 401.1 and 401.9, there are still case mix points to be earned from the combination hypertension codes 402.x (Hypertensive heart disease), 403.x (Hypertensive chronic kidney disease) and 404. x (Hypertensive heart and chronic kidney disease), says Jennifer Warfield, BSN, HCS-D, COS-C, education director with PPS Plus Software in Biloxi, Miss.

Key: Be proactive in how you approach coding for hypertension, Warfield says. Remember, if your patient has both hypertension and chronic kidney disease, ICD-9 assumes a cause and effect relationship. So, you can list a 403.x code for these patients and still earn case mix points.

Caution: If you see that your patient has diagnoses of hypertension and heart disease, the physician must document a link before you can list a 402.x code. Warfield says. Ask the physician if the hypertension caused the heart disease before assuming there's a connection. The same holds true for listing a 404.x code. You can assume the link between hypertension and kidney disease, but the documentation must support the cause and effect relationship between hypertension and the heart disease.