Accurate and case-specific coding is vital for success under the Patient-Driven Groupings Model (PDGM). It ensures proper payment and addresses patients’ healthcare needs.
Submitting claims with coding errors can result in claim returns and long-term consequences. Agencies consistently submitting invalid codes as the primary diagnosis may face closer scrutiny from regulators.
Here are some key things to keep in mind when coding and critical issues to avoid, as they may raise concerns for auditors:
Reminders
- Diagnoses must be addressed and verified by the physician in the face-to-face documentation
- Diagnoses must be consistent across all documentation in the patient’s chart – the claim, the Plan of Care (POC)/CMS 485, and the OASIS.
- All coding must comply with the official ICD-10-CM coding guidelines.
- Symptoms that are part of a disease process/condition should not be coded unless the coding guidelines instruct otherwise.
- Resolved diagnoses should not be listed.
- Diagnoses must be accurate and clearly explain why the patient needs home care.
- Diagnosis sequencing should reflect the seriousness of each condition and support the provided skilled services.
- The primary diagnosis is defined as the “chief reason the patient is receiving home care” and is the most relevant to the current POC.
- Secondary diagnoses should impact the skilled services provided and be addressed in the POC.
- Each ICD-10 code should be entered at its highest level of specificity.
- Avoid using “unspecified” codes and consult with the physician for more specific codes when documentation is insufficient.
Red Flags
- Using the same top six case-mix diagnoses for multiple patients on different claims
- Each patient’s condition should be evaluated and documented individually, based on the specific severity of their disease processes.
- Listing all diagnoses with an exacerbation and/or onset date as the admission or recertification date on the POC.
- These dates should be specific to each diagnosis and not generalized to one specific date such as the admission or recertification date. While listing these dates is no longer mandatory, if the agency chooses to include them, they must be accurate.
- Coding diagnoses that are not present in the patient’s billing history, except for home care-specific codes like aftercare codes or attention codes
- Physician-originated diagnoses supported by documentation can help avoid this issue from occurring.
- Using acute codes that are not appropriate for home care claims
- Coding manifestation codes as the primary diagnosis.
- Coding superficial wounds inappropriately.
- Clear documentation should support the wound code used on the claim, OASIS, and POC.
- Having documentation that contradicts the type of wound/ulcer being treated.
- Seek physician clarification if documentation regarding ulcer type is unclear.
- Coding cancer diagnoses incorrectly as acute (active) versus being part of the patient’s medical history.
- Always verify that the physician’s documentation supports the current active treatment and/or not eradication of cancer and does not merely indicate the patient’s medical history.
- Coding diagnoses that are not supported in the POC, medication profile, and/or referral documentation
While agencies may already possess a fundamental grasp of PDGM coding, applying best practices can help further improve reimbursements and minimize the risk of audits or claim denials. It is crucial for coders to thoroughly analyze each patient case and collaborate proactively with other departments, including intake, billing, and QA. This collaborative effort ensures that documentation is comprehensive, consistent, and provides robust support for the relevant diagnosis codes associated with the patient’s case.