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Posts from the ‘ICD-9 coding home health’ Category

Work with Me, Folks!!!

deniedFor the past several months, I have been arguing with pretty much every payor source for home health there is trying to get clients paid.  After working with dozens of clients in multiple states, I am fairly confident in stating that some of you simply do not want to be paid.  If you did, you would give me and other consultants and lawyers something with which to work.  Just to be clear, I cannot work with:

  1. ‘Take meds exactly as ordered’.  (variant:  take meds at the same time each day.)   It does not require the skills of a licensed nurse to tell the patient to take meds exactly as ordered. The general rule of thumb is that if you can learn it on Oprah, it probably isn’t skilled.
  2. Duplicate medications.  Alone, duplicate medications place a patient at high risk for adverse events.  Combined with number 1, it shows anyone who cares to read that the patient should not take meds exactly as ordered.
  3. I read this in a clinical record:  I noticed the patient had enough money to buy cigarettes, but claims she can’t afford her medical supplies.  Work with me people!  You don’t get paid for your personal judgment.  The patient was at 77 percent of the poverty level. Refer to evidence based practice when you feel tempted to commit to legal documentation your personal disapproval.
  4. Prior to charting edema on a lower extremity, please ensure that the extremity is present.  I promise that if you have check boxes for right and left pedal edema and you pull all your patients who have less than two lower extremities, you will find phantom edema.  The same applies to diabetic foot teaching, pedal pulses, etc.
  5. It is not enough for a physician to document that a patient has a diagnosis.  You must also know what the diagnosis is and how to provide nursing care for the condition.  I just read an admit for a patient who was referred with Pickwickian Syndrome which was named for a very round faced portly character in the first novel written by Charles Dickens.  Because Mr. Pickwick was known largely for his girth, the condition has been renamed  ‘Obesity Hypoventilation Syndrome.  There were no orders for diets or attention to respiratory status.  I  don’t think the nurse looked up Pickwickian, do you?
  6. Diabetes Type I and II are not interchangeable.  Work with me, folks.  These older names for diabetes confused a lot of people so they have changed to simply Type I and Type II.  Type I diabetes accounts for less than 5 percent of diabetes in the elderly.  What on earth are y’all gonna do when when they recognize diabetes 1.5 as a separate diagnosis? (For now, just code as 250.00.)
  7. MD Awareness Month.  It must be MD Awareness Month because every day I read about an MD who is aware.  It goes something like this.  ‘Pt’s blood pressure is 190/100.  Patient has not taken medications.  MD aware.’  I believe that is a convoluted way of stating that you didn’t call the physician as warranted by the MD stated parameters.
  8. Someone named Pt/Cg is wandering through the homes of all home health care patients in the country.  Typically this occurs in computerized documentation that has not been edited correctly.  It makes less than no sense that you taught pt/cg in an Assisted Living Facility that Alzheimer’s is a progressive neurological disease which results in mental deterioration and eventually death.  Which caregiver did  you teach?
  9. Notifying the caregiver is a bad idea.  Imagine if you had an INR come back high and you notified the caregiver to hold the Coumadin and documented that you did so.  What if the patient had multiple caregivers and none of them held the coumadin?  What if the patient had a bleed into their brain and none of the caregivers remember the conversation and you didn’t write down a name.  Think that’s over the top?  It is.  But it happened to a client a year or so ago.  Caregivers have names for a reason.  Use them.
  10. Repetitive teaching.  The second most common reason for denial is that the documentation does not meet the standards for reasonable and necessary care.  Teaching is the most frequently provided skill in home health.  You with me?   So, in order to be paid for your services, you must teach original material or have a reason for re-teaching.  It is unreasonable to teach diabetic diet, foot care, skin care and insulin injections in a single visit.  Don’t chart that you did.  Use teaching guides.  Your patient is elderly, in pain, has poor vision, intermittent confusion, and takes drugs that impair mentation.  That might be something to keep in mind. Take your time.  Teach at the pace the patient learns and document what you did.

So, maybe I am a little frustrated this weekend but I love my job and I love home health and I take it a little personally when payor sources deny claim after claim sending the message to my clients and colleagues that what we do is not worth getting paid.

How to Minimize Income

I have never been inside an agency that has too much cash on hand but if you happen to be one who would like to earn a little less money, I can help. Follow the steps outlined below to minimize your income and prevent the problem of not knowing what to do with all your extra money.

  1. Do not invest in ICD-9 or OASIS training for your staff. They can read the internet just like everyone else.
  2. Make sure that every patient in your agency is scheduled to be seen by a nurse once a week for nine weeks. It doesn’t matter how many or how few visits are needed to provide good care. What’s important is that it is easy to follow a 1w9 pattern.
  3. Do not waste your time putting in processes to manage therapy. You only stand to make money if therapy is tightly managed and missed visits are made up as quickly as possible.
  4. Make frequent use of the hospital. Not only will you lose money by providing extra care to patients discharged from the hospital but your patients might just be safer there if you are planning on implementing any of these measures.
  5. Do not provide any management training for your nurses. Simply expect that because they are ideal clinicians that they will know how to manage a business and staff.
  6. Finally, hire your staff indiscriminately. Anyone with an R and an N behind their name can do OASIS. If you are bound and determined to keep extra cash to a minimum, treat the nurses as though they are disposable and easily replaceable. Certainly that is the case if you are not looking for loyal, qualified employees.

Anyone who tries any of these strategies, please post a comment so we can evaluate their effectiveness.

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

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.

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            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.


            Home Health ICD-9 Coding Guidance

            Our friends at CMS have issued new diagnosis coding guidelines for home health. A link to the document can be found to your left under Essential Links.

            Essentially, this is a 27 page document that includes numerous charts for assistance is choosing primary and secondary diagnoses. On first review, there appears to be nothing earth shattering about the guidelines but the charts and explanations might serve as ideal teaching tools.

            As always, Haydel Consulting Services LLC is recommending advanced ICD-9 coding training for as many clinicians in your agency as you can afford. The CMS document, in and by itself, will not produce competence in ICD-9 coding. But, as a reference tool, it appears to be quite useful.

            Questions and comments are always welcome by clicking on the Comments section below or emailing to

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