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Diagnosis Coding :

6 Steps To Error-Free Diagnosis Coding

Published on Wed May 26, 2004

Keep reimbursement thoughts out of diagnosis decisions.

If your nurses are spending too much time figuring out a patient's primary diagnosis, they might not understand the process -- and mistakes could come back to haunt you.

Caution: Upcoding remains a major government focus under the prospective payment system. And choosing the wrong primary diagnosis is an easy way to find yourself in trouble, says consultant Pat Sevast with American Express Tax and Business Services in Timonium, MD.

Because ICD-9 codes used to answer OASIS questions M0230, M0240 and M0245 affect the case-mix weight and are part of the calculation for the home health episode payment rate the feds are scrutinizing them, she cautions. This means codes have to be both valid -- having the right number of digits -- and accurate in reflecting the patient's condition, she adds.

Protect yourself: Sevast offers these tips for choosing the correct primary diagnosis code:

  • Never consider the point value toward reimbursement when choosing the primary diagnosis. This will only cause you trouble with the feds who already suspect providers of manipulating the system.

  • Choose for the primary diagnosis the one that "is most related to the current home health plan of care," Sevast says.

    Warning: It may not be the reason the patient was admitted to the hospital, or the most obvious recent medical problem.

  • The primary diagnosis follows from the OASIS assessment. First assess the patient to determine "which body systems are normal and abnormal ... and then which of the abnormalities are problematic," Sevast advises. You'll need to address the problems and each is likely to be linked directly to a diagnosis. Then you list them in order of priority, she explains.

    Tip: This can't really be done until the end of the OASIS assessment.

  • When a patient has multiple medical problems and is being treated by multiple disciplines, your primary diagnosis usually reflects "the highest level of acuity" as listed from 0 to 4 in M0230 and M0240, Sevast explains. Then the others are listed in order of descending priority.

  • If you're still confused, make sure every problem addressed in the plan of care is linked to a medical diagnosis. Then ask "what requires the most intensive level of service," Sevast says. If the patient is receiving multiple treatments, assign each one to the appropriate diagnosis to see which diagnosis has more treatment, she suggested.

  • Look at the frequency of the visits to see which diagnosis is receiving the most attention in the home health treatment plan.

    Remember: Don't stop with the primary diagnosis. You must list all pertinent diagnoses "relevant to the care plan," Sevast instructs. "When in doubt, put it on the list." Surveyors may look for a diagnosis relevant to every intervention in the care plan, she warns.

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