Eli's Rehab Report

Published on Wed Sep 14, 2016 PDF

Accurate diagnosis coding in the spotlight.

ICD-10 diagnosis coding plays an important role in proposed changes to the home health prospective payment system.

In a new payment reform model that the Centers for Medicare & Medicaid Services highlighted in its most recent Home Health Open Door Forum, contractor Abt Associates explained the six clinical groups the Home Health Groupings Model would use.

Based on the primary diagnosis you list in OASIS, the HHGM system would slot episodes into six categories. CMS and Abt haven’t yet revealed which exact diagnosis codes would qualify patients for which categories, but it will do so when it issues its technical report on the HHGM for comments later this year, according to the 2017 HH PPS proposed rule.

Watch out: When sorting the codes into the six clinical groups, Abt found that not every code corresponded to a category. In some cases, the system would return claims to providers to furnish more “appropriate, definitive coding,” the Abt staffer said.

Here are the six clinical groups and the services Medicare believes they should indicate:

1. Musculoskeletal Rehabilitation: Therapy (PT/OT/SLP) for a musculoskeletal condition

2. Neuro/Stroke Rehabilitation: Therapy (PT/OT/SLP) for a neurological condition or stroke

3. Wounds — Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care: Assessment, treatment & evaluation of a surgical wound; nonsurgical wounds, ulcers, burns and other lesions

4. Medication Management, Teaching and Assessment (MMTA): Assessment, evaluation, teaching, and medication management for a variety of medical and surgical conditions not classified in another group

5. Behavioral Health Care: Assessment, treatment & evaluation of psychiatric and substance abuse conditions

6. Complex Nursing Care (Based on answers to OASIS item M1030, M1410, and M1630): Assessment, treatment & evaluation of complex medical & surgical conditions with nursing interventions including IV therapy, total parenteral nutrition, enteral nutrition, ventilator, and ostomies.