A Lisa Selman-Holman blog
We’re teaching in Texas in July! Come join SHA for coding education in McAllen July 9-10 and Dallas July 30-31.
Beginners: The coding book is friendly if you know how to use it!
Intermediate: Go over basic skills, move to PPS, case-mix, RAC targets, and complicated scenarios.
Today is glaucoma awareness day, so let’s take a quick look at this eye disease.
The basics: Increased introcular pressure causes optic nerve damage and loss of vision, beginning with peripheral vision. Early stages of glaucoma do not have symptoms.
Most glaucomas are in Category 365, except for congenital glaucoma (743.20-743.22) and absolute glaucoma (360.42).
Two years ago, CMS removed the manifestation status of all glaucomas except 365.44, Glaucoma associated with systemic syndromes. This code is used when glaucoma is a manifestation of diabetes, as well as several other diseases.
In these cases, make sure to code the diabetes or other underlying disease first.
For congenital glaucoma, it must be documented by the physician.
Question: Is it possible to keep a patient for home health only to perform PT/INR labs. Initially we received this patient for CVA. She currently is stable but still requires therapeutic drug monitoring. Every other disease process is stable and been taught on. Is therapeutic drug monitoring a valid reason, and can it be the only reason why we continue to have the patient on board?
Lisa says: Venipuncture is a skill but not a qualifying skill for Medicare home health. A patient such as you described is usually receiving observation and assessment as the skill. Observation and assessment is considered a skill only if there is a potentially fluctuating condition. If there have been no changes, then O and A probably is no longer skilled.
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I continue to receive questions on hypertension (401.9) and pulmonary hypertension (416.0). One reader recently asked if I would consider pulmonary hypertension to be a comorbidity that should always be coded.
Remember that the list of comorbidities “that should always be coded” are examples of diagnoses likely to impact care because of the chronicity. When you code a comorbidity … a condition that affects the patient’s health, or is such an impactful disease that even if it is under control can affect the patient’s health detrimentally and quickly … that you must think about the treatment aspect.
Is pulmonary hypertension under treatment with medications, education, or intervention? Yes, code it. Does pulmonary hypertension have the potential of impacting other conditions? Probably, but remember that CMS requires that comorbidities be addressed in the POC, so what are you doing about the pulmonary hypertension?
Keep in mind that “chronic” does not automatically mean that a disease is a comorbidity. GERD (530.81) is a great example. A patient may have chronic GERD, but if medication has taken care of symptoms for a length of time, what justifies its “status” as a comorbidity? It’s not being treated by home health professionals. There aren’t interventions.
I love this question … someone is thinking on their feet!
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As we start our new code year, we’re always scrambling for education on codes, but what about other subjects, like PPS fundamentals or OASIS best practices or coding and filling out OASIS information on those pressure ulcers?
It’s time for new education in the new year, and I’m offering these in the month of October, in addition to my live education around the country.
PPS Fundamentals, Monday, October 11
Understand the fundamentals of PPS that are essential to agency operations for administrators, quality personnel and coders. This includes information on:
12pm -1:45pm CST
OASIS C Best Practices, Monday, October 18
What is a “best practice”? And what does it mean to your agency? The first quality reports have been released from OASIS C. How did CMS derive the information and how can your agency do better next time? In this education, we will:
12pm -1:45pm CST
Pressure ulcers, coding and OASIS-C, Monday, October 25
Coding pressure ulcers and responding to OASIS data items regarding pressure ulcers are some of the most difficult areas of home health practice. Lisa will lead your staff through the latest guidance on answering OASIS-C regarding pressure ulcers and contrast that with coding guidance. Lisa will:
12pm -1:45pm CST
Code changes happen tomorrow … doesn’t Oct. 1 always sneak up on us?
To look at my overview of the changes, just go to my Musings-of-a-Codeaholic page!
Along with code changes have come some guideline changes, and I want to remind everyone what CMS is now saying about “with”:
“The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.
“The word “with” in the alphabetic index is sequenced immediately following
the main term, not in alphabetical order.”
The bolded text is the part that takes effect Oct. 1 This should eliminate a lot of confusion over relationships with this important preposition.
Looking for guidelines? Look no further!
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Question: People were overusing 781.2, and then the criteria changed on how to capture case mix points: You also needed and ulcer and/or IV therapy. Is this still the criteria?
Lisa says: The criteria haven’t changed since January 2008. Abnormality of gait is still case mix, but does not receive points unless the patient also has a pressure ulcer, it’s an early episode and there are less than 14 therapy visits. (See row 19 of CMS’s Table 4 for the official cite.)
Infusion therapy has never been part of the criteria for 781.2. Always remember that you code for medical necessity and services provided, NOT case mix.
2011 Coding Guidelines have been updated, and there are very few additions to the Guidelines. I am still scanning for any deletions (which are not noted by CMS). Here, first, are some additions to watch:
In the Conventions section, there is a clarification of “with” when used in the Tabular List and Index. With “should be interpreted to mean ‘associated with’ or
‘due to.’”
There are two notes at CVA. Neither applies to home health, but I’ll write about them because CVA is such a watched (and miscoded) diagnosis.
One note at CVA talks about coding neurologic deficits regardless of whether they resolve prior to discharge. Remember that this applies to acute discharge, not home health.
The second note states that 438 codes are for late effects of cerebrovascular disease (which we know, because we use this code category, note 434), not for neurologic deficits associated with an acute CVA. This simply confirms that 438 codes are for post-acute settings, such as home health. There are no code change implications for home health, and this guidance goes along with 3rd Quarter 2009 Coding Clinic guidance where even resolved deficits are code in acute settings, even if resolved at discharge.
V codes always have changes, and there is a general clarification of what Status codes are, with new guidelines stating that these are …. codes that show a patient is a carrier of a disease, has the sequelae or residual or has another factor influencing health.
Following the changes to the Tabular List, the guidelines now indicate that V07 is appropriate for prophylactic or treatment measures.
Those are the main additions … I’ll post more if there are other changes or deletions I find out about.
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Go to the Musings of a Code-a-holic page to see my thoughts on the Oct. 1 changes!
There is a lot of confusion over skilled care when it comes to venipuncture ….
Venipuncture is considered a skill, just not a qualifying skill. Most likely you are performing observation and assessment of the condition that requires an anticoagulant. If performing the PT/INR by one of the machines, it is still a skill.
To code correctly, code the condition, then V58.83 (Encounter for therapeutic monitoring of medications), and V58.61 (Long term use of anticoagulants).
