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Posts from the ‘Home health diagnosis coding’ Category

Jul 22

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Know Your Numbers Part 1

Management of a Medicare Certified agency has never been a job that allowed for a wide margin of error. In the near future, with payment cuts looming, managing an agency without sufficient information will be a fast trip to failure.

Since the implementation of PPS, we have known that the clinical and business operations can no longer be separate in an agency. My successful clients work within a combined operations model while clients who struggle continue to try to separate these two intertwined components of a home health care agency.

Can you answer the following questions about your agency?

  • What is your average case mix weight for Medicare Patients?
  • What percentage of that case mix weight comes from ICD-9 coding?
  • Is your functional scoring representing the acuity of your patient mix?
  • What do your outcomes look like compared to your competitors?
  • How would you fair during a RAC audit?

If you know the answer to all of the above questions, my hat is off to you. If you know the answers and don’t like one or more of them, relax – you are still ahead of the game because at least you know where to focus your efforts. If you don’t know the answers to one or more of these questions, it is time to find out.

Most software systems should be able to report to you the average case mix weight for your patients. Although you will invariably ask, no one but you can determine what the correct case mix weight for your patients should be. If you have a lot of therapy and very few later episodes, I would expect it to be close to two. Lower therapy and later episodes may bring it down to around 1. The important thing is that you are not leaving legitimate money on the table which a surprising number of agencies do.

ICD-9 coding seems to get more and more complicated each passing year. How do you know that your coding is accurate? What checks and balances do you have in place? Is there a coding expert – certified or otherwise available to your staff?

Functional scoring is often overlooked in the OASIS assessment data. The full impact of the functional domain is not nearly as great as the clinical domain or but if your agency is losing an average of $50.00 per episode on functional scoring, it doesn’t take many episodes for that number to really add up to a real hit. Additionally, it is difficult to support therapy services when the functional domain is artificially low.

If you don’t know your outcomes as well as your competitors’ outcomes, you are operating blind. Your referral sources know them. The state knows them. Your patients have the ability to look at them. Agencies should be prepared to explain any poor outcomes and should be proudly displaying any good outcomes.

Finally, we are holding our breath here at Haydel Consulting Services. RAC audits have begun and CMS has a plan for expanding RAC audits. Keep in mind that Recovery Audit Contractors are paid on a contingency basis. They are financially motivated to find issues with your charts. Only a thorough pre-billing audit and sound billing policies will save you once your agency is selected for review.

In the coming weeks, we will be discussing each of these issues and how to use the information in managing your agency. If you have any questions or comments, please feel free to contact me below in the comments box or by email at haydelconsulting@bellsouth.net.

May 11

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PPS – More than ICD-9 Coding

Clinical record review in the past several weeks has revealed that my clients have greatly improved their ICD-9 coding. It’s really no surprise. Coding classes are offered regularly and there are many great services out there to assist agencies with coding. And coding is critical to home health PPS. No one can deny that.

But what I have been seeing repeatedly is clinical records reflecting very high clinical scores and almost non-existent functional scores. It’s as though once the diagnosis coding is correct, nothing further in the OASIS data set is examined. This morning, for instance, I reviewed a report of a patient who has severe visual impairment, is short of breath with minimal exertion and has diabetic neuropathy. But, as it turns out, this patient is safe to dress by herself, including retrieving her own clothes. And by divine intervention, it is safe for her to bathe and toilet independently.

I have not looked at this patient. Nor would I mention this patient if this wasn’t so very typical of what I have been seeing in charts. And this is costing agencies!

Many nurses think that because a patient is forced by circumstance to perform these activities of daily living that they are able to do so safely and independently. And yet, OASIS instructions are very clear in that safety should always be considered in responding to the OASIS functional domain questions.

For more on making PPS work for you, check out the link to the right of the page. If you have any questions, please feel free to contact us at haydelconsulting@bellsouth.net or leave a comment below.

Jan 12

OASIS-C Comments

We have finally submitted our comments regarding the proposed OASIS-C dataset. You can view them here.

  • In short there will be 40 new questions on OASIS C that are not currently on OASIS B-1
  • 10 questions that we currently answer on B1 that will not be carried over to OASIS C
  • 70 questions that were on OASIS B1 that had their MO numbers changed. Note: Most MO numbers have been replaced with M numbers
  • 50 of the 71 questions that had a numbering change also had a change in the language or skip pattern
  • 21 changes were merely numbers.

You comments as always are always appreciated. Please email us at Haydelconsulting@bellsouth.net or leave a comment below.


Jan 4

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ICD-9 Coding Guidance from Vonnie Blevins, HCS-D

Below is commentary on the new Attachment D related to home health ICD-9 Coding provided by Vonnie Blevins, HCS-D. Vonnie is an active participant on the Home Health Coding listserv and truthfully, I have learned more about coding by reading her posts than most any other source. It is also rumored that Vonnie will be hosting a Decision Health Audio Conference later this month. Check back at our blog for details or email Vonnie directly at mime1lead@aol.com.

Everyone needs to read the entire attachment D  carefully and step back, take a deep breath and remember to follow official coding guidelines as well as the CMS direction.  The biggest changes in the Attachment D that I see are:

    • If the case mix diagnosis meets current guidelines as well as being replaced by the V code, place it in M0240, not in M0246 In order to put a diagnosis in M0246, the case mix diagnosis must meet all of the requirements outlined in Table 2A and not be a current diagnosis (resolved)
    • Any case mix diagnosis that is included must also be addressed in the plan of care (even the comorbididities that we have automatically coded before), but that should not be a big deal because we are generally at least monitoring these conditions and would notify the MD if there was a change in them, so we need to document this to cover these codes.

      The attachment d update clearly states  avoid the practice of allowing the case mix status of a dx to influence the dx selection process. HHA’s are expected to prevent “coding for payment” from occurring.  Code only the dx supported by the pt’s medical documentation hh poc and clinical comp. assessment. if the dx under consideration is not supported by the pt’s medical condition and clinical care needs, then the dx must not be reported on the oasis.

      • The Attachment has a error in listing Neuro 3 when it should be Neuro 1 as the third diagnosis category that gives more case mix points when listed primary versus secondary diagnosis
          • The joint replacement is a bad example because the osteoarthritis in the replaced hip is gone.  To use the osteoarthritis diagnosis in M0240, I think we would need clarification from the MD that the patient still has osteoarthritis in other areas of the body. If the condition is resolved then we do not code it in mo240.

            in a nutshell

            only use mo246 if the condition is resolved and will not be in mo240 and meets the criteria to receive case mix points (example appendicitis),  if not documented as resolved then still code the condition in mo240 (ex. CAD 414.00) and if a v code replaced a neuro1/skin1/dm diagnois in mo230 put that dx in mo246.

            address comorbidities – things like monitor 02 stats due to COPD/ assess c/p status/monitor/teach hypo/hyperglycemia/ monitor bs log due to dm/ things like that to address them. it has to show on the poc how you are monitoring or treating these dx to receive the case mix points for them.

            The big thing is to make sure you understand table 2a and b and know when the dx meets the criteria for case mix points so you will know when to put them in mo246 if they are resolved and not in mo240.

            VONNIE P BLEVINS HCS-D
            PO BOX 362
            CONETOE NC 27819
            252.823.4217 HOME/FAX
            252.382.1523 CELL

            Dec 23

            1 Comment

            Santa Baby

            Dear Santa:

            I hope you and the elves are doing well. I saw a few elves at dinner the other night. Frankly, they were tanked and I hope that doesn’t impede progress in the North Pole.

            But, in case it does, I am humbly preparing a list that doesn’t require a bunch of drunken elves to deliver; not to mention an antiquated sleigh that apparently is not equipped with GPS. I refer to the time you brought the kitten I wanted to the neighbors and I got stuck with the Easy Bake Oven with a stupid light bulb instead of gas to provide heat.

            But now, fat man in red, I am giving you the opportunity to make up for the lame Easy Bake Oven by bringing me a new set of coding guidelines for home health. I want a coding system with random assignment of codes. I want a coding procedure that doesn’t have manifestation codes, V-Codes, E-Codes or anything else of the sort. If you ever read the list of E-Codes, you would know how depressing it gets to read all the bad things that can happen to the human body. Such knowledge does not impart the Christmas Spirit you claimed to promote before the Easy Bake Oven fiasco.

            And of course, the kitten you gave the neighbors got run over in front of my driveway. Did you forget that? Would you like to make it up?

            How about a Home Health Assessment that isn’t so complicated it requires letters and numbers just to get the version straight? The term OASIS conjures up visions of palm trees and beaches and relaxation. It is a sick, sick joke perpetrated on nurses and is about as funny as the kitten being run over in my drive way.

            My therapist seems to think I am making progress about the events surrounding your gift of a chemistry set to my brother. The scars are fading and I am once again able to smell sulphur without remembering all my Barbies perishing in the great fire that also took out my Barbie mansion, and the GI Joe tank Ken used for transportation. I still have nightmares about little melted pumps littering the floor of the play room.

            I know it would help me with my resentment towards you if only you were able to bring to CMS some common sense about medical billing. Here’s how it should work. You take care of a patient. You see how much it costs to do so. You tack a modest amount on for a profit. You submit the claim. Medicare pays.

            How hard is that? It should be easier than watching a little girl spend an entire weekend burying Barbie Dolls in her back yard cemetery that spans over an acre.

            And if none of that is possible, then please just bless all of those I know with love and good fortune for the New Year. We will take care of the rest.

            julianne

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