With the implementation of PDGM, home health coding has become more challenging due to increased documentation requirements and constantly changing guidelines. In addition, agencies must work closely with physicians to ensure complete documentation is obtained to support coding decisions. All these factors can consume significant time and resources.
Failing to keep up with these challenges can result in coding errors and delayed or improper payments. Practical knowledge based on real experience can make a big difference in helping agencies achieve optimal reimbursements.
Here are some coding tips and best practices to consider:
Quick Review of Basic Coding Principles
Before anything else, here’s a brief overview of the essential requirements for accurate and compliant code assignment through proper documentation:
- The physician or qualified provider must state or confirm all diagnoses.
- Never assign diagnoses if the provider uses indefinite terms, such as “likely,” “suspected” or “consistent with.”
- Keep in mind that diagnoses cannot be assigned from lab reports or imaging without a physician’s interpretation of those results confirming the diagnosis.
- Reference data from supporting medical records to justify code assignment.
Coding Tips and Best Practices
- Comorbidities
- Make sure that comorbid conditions exist at the time of the assessment and document them in the OASIS. The patient’s Plan of Care should address these conditions, as they can potentially affect the patient’s response to treatment and rehabilitation prognosis.
- Pay attention to the Social Determinants of Health (SDOH) section in the OASIS. This section describes the patient’s ability to receive and access appropriate healthcare services and is a crucial tool for risk adjustment.
- Accurately document the laterality of conditions to assign appropriate codes. When laterality is not specified in the F2F documentation, check other medical records available. It is generally best to avoid using “unspecified” codes, as they do not fall under any comorbidity subgrouping.
- Coding Specificity
In general, codes that lack specific anatomical location and laterality are not acceptable, although there are a few exceptions to this rule.- Dysphagia codes – With a few exceptions for dysphagia codes, R Codes (which encompass symptoms, signs, and abnormal clinical and laboratory findings that cannot be classified elsewhere) cannot be used as the primary diagnosis. However, in the CY 2020 final rule, CMS determined that certain forms of dysphagia lack other definitive diagnoses, and thus R-codes would be acceptable for reporting the primary reason for home health services. As a result, the following R-codes are assigned to the Neuro Rehab clinical group: R13.10, R13.11, R13.12, R13.13, R13.14 & R13.19 – Multiple Dysphagia codes.
- S and T codes – CMS requires the identification of the specified site for many of the S and T codes where the fracture or injury is unspecified. Nevertheless, it is unlikely that the exact type of injury or fracture would affect the treatment or intervention. Many of these codes can be assigned to a clinical group, such as the musculoskeletal group or the wounds group, as they are appropriate for such categorization.
- Code Sequencing
The positioning of codes can significantly impact a claim’s clinical grouping and trigger reimbursement level adjustments. Understanding the complexity of diagnosis sequencing (identifying primary and secondary diagnoses) is crucial, as a diagnosis documented as the primary reason for home health on the face-to-face encounter may actually be classified as the first secondary diagnosis due to rules such as manifestation, etiology codes, or “code first” coding instructions. When assigning a primary diagnosis, it is necessary to consider the primary service and the highest frequency of discipline. Given these factors, there can be variations in the sequencing of diagnoses. - Complete and Specific Documentation
Ensuring accurate coding under PDGM requires agencies to have highly detailed documentation from physicians and/or referral sources. To achieve this, agencies can take the following steps to ensure proper documentation:- If the referral source or physician gives an unacceptable primary diagnosis, ask for the underlying cause because it is often an acceptable primary diagnosis.
- To ensure accurate code assignment, it’s important to analyze all supporting medical records. These records can provide important information for code assignment and help identify reasons for provider queries. Examples of supporting medical records that can provide insight into code assignment include H&P, discharge summaries, operative reports, labs and imaging with interpretation, and progress notes.
- Referral and Intake
The intake team needs to check if referral documents have enough information. This helps to build good relationships with referral sources and ensures efficiency. There are common issues like incomplete referrals, hard-to-reach sources, and lack of knowledge about clinical groupings among staff. To address these issues, the intake staff can use scripts and checklists to ensure they have all the necessary information. The checklist should include:- Specifically stated referral source
- Home health principal diagnosis
- Physician face-to-face encounter and supporting documentation
- Patient secondary diagnosis information for comorbidities
- Requested services
Realizing Reimbursement Objectives
Accurate coding is crucial for both patient care and financial success in home health. Coders must have the necessary skills to analyze documentation and collaborate effectively with other stakeholders to ensure compliance and maximize reimbursement potential. For instance, effective collaboration between the coding team and the intake team is essential to address common issues like missing information in patient records and knowledge gaps. Without proper documentation, revenue and patient care could be compromised, hence, knowledge and well-coordinated processes are key.