OASIS Alert

Published on Thu Nov 27, 2008 PDF

Doubling up on codes could lead to increased payment.

You don't have to worry about repeating a case mix diagnosis at multiple levels in M0246. You'll either reap more payment or not be affected at all -- but the Centers for Medi-care & Medicaid Services won't be breathing down your neck.

In most cases, repeating the case mix diagnosis in M0246 or using the same one you put in M0230 or M0240 won't affect your payment, according to CMS's clarification on the OASIS Certificate and Competency Board 's (OCCB) website this spring. However, in complex coding situations, that multiple code could increase your payment.

M0246 example: "When a V code repl-aces a condition that must be reported using mandatory multiple coding, and both the etiology and manifestation codes are case mix diagn-oses from different Diagnostic Groups, PPS payment model criteria will determine which of the two codes will bring the most points, and it will contribute to payment, and the other will not," the clarification states.In this situation, the case mix diagnosis that wasn't used could contribute toward payment if listed again at another level. However, if your clinician isn't sure where to put each case mix code for optimal reimbursement and only lists the codes at one level, you'll lose out on any potential reimbursement.

Failsafe: "Go ahead and list the codes even if you aren't sure because there's no reason not to," explains Karen Vance, supervising consultant with BKD in Springfield, Mo. The extra code doesn't knock you out of compliance and CMS will only consider it for the appropriate number of times, she says. Also, the repeated code may impact your risk adjustment. "Eligible diagnosis codes from M0246 are considered for risk adjustment calculation, but are only considered once," the OCCB clarification states. That means your ex-tra code may impact the calculation but it won't throw CMS for a loop or cause your risk adjustment calculation to be wrong.

Translation: "CMS does mean for you to put non-case mix codes in M0246," says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, Texas. "These codes won't impact payment -- they'll only impact risk adjustment, but that's a good thing," she says.

Example: Your patient had valve-replacement surgery to correct mitral valve stenosis and you are providing aftercare. You would list V58.73 (Aftercare following surgery of the circulatory system) in M0230. The mitral valve is gone, so you wouldn't list 394.0 (Mitral stenosis) in M0240. And code 394.0 isn't case mix, so if you follow only the Chapter 8 instruction, you wouldn't list it in M0246. But you would then lose out on the risk adjustment for 394.0.

New way: You can list this code in M0 246 and reap the benefit of the risk adjustment.

Bottom line: Whenever you encounter the opportunity to flesh out your patients' status by repeating case mix diagnosis codes, it may be in your agency's best interest to do so simply so that you don't miss out on the chance to improve your payment or risk adjustment.

Bonus: Want a M0246 tip sheet to help you navigate the OASIS diagnosis code reporting process? Email the editor at kellyq@eliresearch.com with "M0246" in the Subject line for a free pdf copy.