October 21, 2012
Question: I recently attended your conference you advised us about procedure coding–that it was no longer necessary to report them as CMS does not count that. Did I understand this correctly??
Lisa says: Procedure coding is no longer required as of 4/20/2011. M1012 must still be answered but you may answer NA or UK on everyone if you’d like. There is also no requirement for surgical procedures on the POC.
July 9, 2012
I recently received a query on hypertension codes. A client was saying that 401.9 and 401.0 are no longer legitimate, as of January 2012, but coding books ordered after that have these codes.
My response is below:
The coding manual is correct. The codes are valid codes. The coding guidelines have not changed on using 401.9 and 401.1. If the patient has hypertension and there is 1) no stated or implied relationship documented by the physician between the hypertension and heart failure and 2) no chronic kidney disease or renal sclerosis, then the 401 category is correct for hypertension.
Furthermore, if the 401 category is correct (as is usual), then 4th digit 9 (unspecified) is usually correct because the physician doesn’t specify benign or malignant.
What did change is the case-mix status of 401.9 and 401.1. Those two codes are no longer case mix meaning they do not earn points. But alas, do not be discouraged. Many patients who have hypertension also have CAD, chronic ischemia, heart failure or the like, and those diagnoses earn the same points that 401.9 and 401.1 used to earn.
Continue to code hypertension when it is pertinent to your POC. The codes ARE allowed. What is important is to NOT change the code you use for HTN just to get points. CMS is looking for that type of behavior.
The coding manuals were published prior to the final rule from CMS on case-mix status so all you’ll need to do to update your manual is to write “NO $” next to those two codes.
March 20, 2012
From CMS Q&As …
Question: Our clinician reported an ostomy as a surgical wound in the OASIS M1340, Surgical Wound item. The clinician no longer works for the agency, so we cannot contact her about the error. Can this OASIS change be made by the DON without speaking to the clinician?
CMS Answer: You have described a situation where a true OASIS scoring error was discovered during the audit process. The assessment was complete. The patient had an ostomy, a clear, non-disputable fact based on the entire clinical record. The assessing clinician responsible for completing the assessment misunderstood, wasn’t aware, or made an error based on the OASIS scoring guidance, which states all ostomies are excluded as surgical wounds in M1340.
HHAs should have a policy and procedure for correcting errors that involves the assessing clinician. The policy should follow established clinical record professional practice standards and guidance found in relevant CMS regulations and guidance. Normally, if an error is identified through audit or review, the individual who made the original entry into the patient’s record would, whenever possible, make the necessary correction by following agency policy. A correction policy may allow the auditor who found the error to contact the clinician, discuss the discrepancy in the medical record and make the correction following your policy including information such as who discovered the error, and the date and time of communication with the assessing clinician who agrees that it was an error. Correction of an error will not impact the M0090, Date Assessment Completed.
In a case where, as you have described, the original documenter is not available, the clinical supervisor or quality staff may make the correction to the documentation following the correction policy. The supervisor must document why the original assessing clinician is not available to make the correction and how the error was identified and validated as a true error. When corrections are made to assessments submitted to state, you must determine the impact of the correction on the POC, HHRG, the Plan of Treatment, RAP and make corrections to those documents and billing, as applicable.
When the comprehensive assessment is corrected, the HHA must maintain the original as well as subsequent corrected assessments in the patient’s clinical record per requirements at 42 CFR 484.48.
CMS urges HHAs to make corrections and/or submit inactivations as quickly as possible after errors are identified so the state system will be as current and accurate as possible, as the data is used to generate OBQM, OBQI, PBQI, Patient-Related Characteristics Report and HHRG.
Follow the guidance found in CMS Survey & Cert Letter 01-12 New Outcome and Assessment Information Set (OASIS) Correction Policy for Home Health Agencies (HHAs)—ACTION and INFORMATION.
June 13, 2011
Question: We have a doozie of a patient.
He was discharged from an inpatient stay at the hospital for abscess under the right axilla for which he had an I&D. We are seeing him for wound care following this procedure. The wound is clean now without any infection presently. He also had a pulmonary embolism that was treated in the hospital with lovenox and Coumadin. He is still on Coumadin, of course, and this affects his dressing changes as he bleeds quite a bit during the dressing changes. Plus we will be monitoring his PT/INRs of course. He also has LE DVT.
The primary reason that we are seeing him is the wound care.
He is a type 2 diabetic (fairly recently diagnosed) and just started on Levamir while in the hospital. This may delay wound healing, so I know that it needs to be pretty up in the diagnosis chain.
Past history includes CA of the appendix (which has been removed surgically), but this metastasized to the abdomen (does not give specific organ, but I am assuming colon because he has a colostomy) and the lung. He is independent with his colostomy, so I know not to code “ATTN TO” on this one. He also has hx of prostate CA as well.
His cancer is still active as he is on chemotherapy. It is just on hold related to the fact that he had the abscess.
He is morbidly obese, has HTN (with several meds) and GERD.
I am in desperate need of assistance on this one.
Lisa says: He’s a doozie all right!! I think I would still code the wound as an abscess. Follow with the PE, DVT, diabetes, HTN, secondary site(s) of Ca. Follow with V58.83, V58,61, V44.3 and the rest of the codes. Once you’ve coded the primary, you just have to consider the seriousness of the other conditions and importance to the POC. Push your V codes to the bottom.
May 26, 2011
Thank you to a subscriber who asked about a recent entry … sometimes we all lose track of the information floating in our heads:
Question: I have been following your blog entries. On April 15, 2011, you blogged that the resolved case-mix codes need to be placed on the POC. You suggested field 21. In order for me to change a current practice, I need the resource for your quote. I can not seem to find it in the CoP’s. Would you mind giving me the resource?
Lisa says: That was actually an older blog that got recycled by mistake.
There was a requirement in the OASIS manual, but when the OASIS manual was revised it was omitted. We dont know whether it was omitted by mistake or on purpose.
May 18, 2011
Question: We’ve heard that we don’t have to report procedure codes, but we’re confused about this. Are there any legal problems in using procedure codes? I personally do not use them.
Lisa says: The last quarterly update from CMS included a statement re: procedure codes. CMS does not use them for anything so you can continue to code procedues or mark NA or UK. The POC no longer has to include procedure codes, either.
April 15, 2011
Just a reminder that all resolved case-mix codes, not just active codes, need to be on the POC.
Because CMS may pay case-mix for these codes, they need to be put in the POC, but not in Fields 11 and 13 of the 485 … those are for active illnesses/disease.
There isn’t an “official” spot to put these codes, but I like Field 21.
November 29, 2010
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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