OASIS Alert

Use these strategies to receive accurate reimbursement, avoid downcoding and minimize claims returns.

Unless you can afford to hand money back to the government, it's time to focus on coding errors.

Diagnosis codes are an important component of the Health Insurance Prospective Payment System (HIPPS) codes home health agencies use to bill Medicare for their services. If the regional home health intermediary selects a claim for medical review, the reviewer validates the HIPPS code billed by comparing it with medical record information to ensure correct reimbursement of the episode.

HIPPS codes are reduced when documentation does not support the code billed, says RHHI Cahaba GBA in a recent home health update. This occurs when medical record documentation does not support or conflicts with the OASIS assessment, when services were provided without a physician's order, when services billed were not documented and when services were not medically necessary, Cahaba says.

Agencies looking to prevent coding-related cash flow problems in 2004 can begin with these five actions, experts recommend:

1. Put payment codes in M0245. It will take some time to understand the changes V code use brings to diagnosis coding, but the sooner you figure it out, the better your profitability will be. Whenever a V code replaces a case mix primary diagnosis - one that would have resulted in additional reimbursement for the episode - you must complete M0245 to get paid (see Eli's OASIS Alert, Vol. 4, No. 7, p. 63).

2. Document to support your decision. Even if your choice of primary diagnosis is accurate, the fiscal intermediary can downcode (and pay you less) if the record as a whole doesn't support your choice, warns consultant Pat Sevast with American Express Tax and Business Services in Timonium, MD. The plan of care and visit notes must include details the reviewer would expect to see for a patient with the diagnosis you reported.

3. Take "Excludes" notes seriously. Using codes the ICD-9 defines as mutually exclusive will result in a claim RTP (return to provider) and payment delays. For example, the 332.0 code for Parkinson's Disease now excludes dementia, because a new code for 2004 - 331.82 - covers dementia with Parkinsonism. If your OASIS assessment includes separate codes for dementia and Parkinson's Disease, you'll see your claim returned for correction, says consultant Linda Dilts-Benson with St. Petersburg, FL-based Reingruber & Co.

4. Use trauma codes appropriately. After hearing so much about misuse of trauma codes, some agencies avoid them altogether (see Eli's OASIS Alert, Vol. 4, No. 4, p. 36). But some home care patients have injuries due to accidents that qualify for the 800- and 900- series trauma codes. These add 21 points to the clinical severity domain (if M0440 is answered"yes") and increase reimbursement, experts say.

5. Drop the fifth digit from 719.7 (difficulty walking). Prior to Oct. 1 ICD-9 coding guidelines required a fifth digit on this code to identify the site responsible for the difficulty walking, Benson explains. Staff often found it difficult to determine the origin of the problem from the available information, so providers will welcome the change, she predicts. But be sure all your staff know about it, because after Jan. 1, regional home health intermediaries' claims processing software won't accept 719.7 with a fifth digit and will return the claim to the provider, delaying payment.

TIP: This code (719.7) is a perfect one to use to check all your coding books and software to be sure they have been updated, suggests coding expert Prinny Rose Abraham with HIQM Consulting in Minneapolis. Since this code used to have a fifth digit, but now has only four, you will know right away if the material you are looking at is the correct coding information for the 2004 fiscal year, she explains.