OASIS Alert

Published on Wed Nov 03, 2004 PDF

You may be using the coding manual incorrectly.

To protect your agency from fraud charges, follow the "read on" rule: Don't stop with the first code that looks good - read on to be sure it's the right one.

Home health agencies that often use 716 codes in M0230 or M0245 may find their fiscal intermediary questioning their claims. "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.

The 11 points you receive for the case mix code can translate to hundreds of dollars extra for that episode - which makes using that code great if you deserve it, but dangerous if you don't.

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 HHAs.

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 adds. This condition af-fects 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 FI downcode your claim.

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 ar-thritis, you see: Arthritis, arthritic (acute) (chronic) (subacute), 716.9x. If you stop there, 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, since you are searching for the most specific code possible.

But don't avoid using arthritis codes: Agencies may not be using arthritis codes even when they are appropriate. Agencies' use of both 715 and 716 as primary diagnosis codes fell steadily from 2000 to 2003 and continues to decline, reports coding expert Prinny Rose Abraham with HIQM in Minneapolis.

Data analysis shows coding 715 in M0230a decreased from 3.6 percent of episodes in the first nine months of 2003 to 1.2 percent in the last three months of that year - after agencies began using V codes, reports Anthony Harris with Santa Barbara, CA-based data services provider Strategic HealthCare Programs. And in 2004, only 0.8 percent of episodes SHP analyzed used a 715 code as a primary diagnosis. Meanwhile, agencies used 716 as a primary diagnosis (or in M0245) less than 1 percent of the time in 2004, according to SHP. 

Possible reasons for continuing declines in the use of these codes include agencies misunderstanding when to use a V code instead of a code for an acute condition; forgetting to put the 716 code in M0245a when a V code replaces it in M0230; overusing  familiar codes out of habit; and overusing V57.1 and abnormality of gait since the October 2003 coding changes, Abraham tells Eli. 

Editor's Note: For more diagnosis coding help, check out Eli's Home Health ICD-9 Coding Alert at www.elihealthcare.com or call 800-874-9180.