There’s more to coding than case mix

There is more to coding than case mix, folks.

I receive this type of question all … the … time …

Do I put a case mix code in M1024 if the V code in M1020 or M1022 is not on the list of “approved” codes that trigger the Grouper to calculate case mix?

The answer I give all … the … time … Yes, code it. That code can impact risk adjustment.

So let’s step back and look at an example.

Your patient has recently resolved breast cancer (174.9), so you code V10.3 in M1022. Do you code 174.9 in M1024?

In this scenario, it’s resolved, so it’s not eligible for M1022.

According to CMS’s Grouper Software, V10 is not on approved list of V codes that triggers the Grouper to check M1024 for potential reimbursement. So do you code 174.9 in M1024 when there won’t be reimbursement for it?

I say yes. There is more to coding that reimbursement. There is painting an accurate picture of the patient’s health, and there is risk adjustment. That cancer has played a significant role in the current state of the patient’s health … why wouldn’t you code it? You can gain risk adjustment, which would impact your outcomes scores and accurately show the acuity of your patient population … why wouldn’t you code it?

I know there are other experts who disagree with my assessment, but until CMS comes out with a rule that says you do not code in M1024 when that V code in M1020 or M1022 does not trigger the Grouper to look for case-mix, I will continue to code that disease for all of the reasons listed above.

As you code, keep coding by services provided and patient care in mind. Your V10.3 may not be in the top six diagnoses. At that point, case-mix and risk adjustment become moot, but the coding of the history of cancer does not. If the breast cancer was significantly impacting care and other disease processes, that V10.3 may be in the top six diagnoses. The Official Coding Guidelines also indicate that the history of malignant neoplasm codes should be used when the cancer has been eradicated and requires no further treatment.

This all could change of course, because CMS is working on changing the OASIS treatment authorization code to include the case mix diagnoses in M1024. We’re all used to change being in home health!!

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