OASIS Alert

Published on Fri Jul 11, 2008 PDF

Avoid reimbursement considerations to enhance coding accuracy.

You may think you have found the right diagnosis code, but if the medical record does not back that up, you won't get the episode reimbursement you expect.

Intermediaries across the country are sending back claims because the primary diagnosis on the OASIS assessment was not the main focus of care for the episode in question, billing experts say.

"According to OASIS guidelines the primary diagnosis (M0230) should be the chief reason for providing home care," says regional home health intermediary National Govern-ment Services, which was formerly United Government Services and Associated Hos-pital Service of Maine. "Home health pro-viders are expected to determine the diagnosis based on the condition most relevant to the current plan of care. The primary diagnosis should represent the most acute condition and the one that requires the most intensive skilled services," NGS instructs.

Consultant Sharon Litwin with 5 Star Consultants in Ballwin, MO sees this problem frequently when she's reviewing records, she tells Eli.

Example: A home health agency re-ceives a referral that says the patient has hypertension, so the clinician puts that down as the primary diagnosis, Litwin reports. The patient's blood pressure is normal upon admission. However, the patient also has congestive heart failure and has difficulty walking and shortness of breath.

The nursing and therapy visit notes fo-cus on the difficulty walking and the CHF. "This is then a problem upon review, because hypertension is not the problem," Litwin points out. "There is no justification for that primary diagnosis."

Diagnosis coding can lose accuracy "when selection of the primary diagnosis is motivated by reimbursement considerations," cautions regulatory consultant Rebecca Fried-man Zuber in Chicago. "While it is important not to leave money on the table, providers also must be sure they are abiding by the coverage and care planning rules when they complete their assessments," she says.

Tip: Remember that the primary diagnosis must be the one "that is related to the preponderance of the care plan," Zuber advises. In fact, "it might not even be the most serious diagnosis the patient has."

Pitfall: Don't make the mistake of choosing a case mix diagnosis code first and "backing into" it for reimbursement reasons, warns consultant Karen Vance with BKD in Springfield, MO. The clinician or coder should base the coding choice squarely on the assessment.

Clinicians should aim to complete "the best possible comprehensive assessment," Vance exhorts. That in turn will drive a well-thought-out plan of care. Then make sure your "defensible" documentation supports that coding choice, Vance says.

Bottom line: Defending claims against medical review denials is all about "going back to the basics," Vance stresses.

Improve documentation by using case management, Litwin suggests. The main disciplines involved in the case and conducting assessments -- often an RN and physical therapist -- should collaborate on the care plan to make sure it has "the proper primary diagnosis for the focus of the episode, and the proper orders including frequency and duration," she says.

Take the time to wait for the team to agree on the coding and sequencing, Vance offers. "Wait for the interdisciplinary coordination -- however that happens in your a-gency," she says. "It may take a few days more to drop the RAP, but it would be more accurate data and fewer corrections would have to be submitted later."

Don't overlook: Once the plan of care is set, it's vital for you to communicate the plan to the other staff who will see the patient so they can document accordingly.

"In many chart reviews I see, this is the breakdown point," Litwin relates. "It is obvious that [the visit staff] have not ... read the plan of care, because they document different items than are on the 485."

Note: For more information and details on diagnosis coding in home care, see Eli's Home Health ICD-9 Alert at http://www.elihealthcare.com/spec_health_icd-9.htm.