Coding Mysteries Exposed

Coding Mysteries Exposed…


It seems that coding myths of all sorts have been running rampant lately among home health coders, both those related to the ICD-9-CM and ICD-10-CM code sets. Coders, don’t believe everything you hear, especially if it doesn’t make sense or seems to conflict with official coding guidelines. Even software scrubbers and edits can cause confusion within agencies when it comes to the assignment of codes, resulting in serious misunderstandings and potential claim errors.


Here is some clarity on a few of these myths and rumors:


#1)Hypertension coding- Since the change in case mix points to hypertension codes in January 2012, agencies and coders seem to be increasingly confused on how to use these codes. First of all, let’s clear the air on the rumor that “401.X codes are no longer valid codes.” They sure are! This rumor originates from the removal of case mix points for the 401.X codes, as well as the fact that many agencies have received ADRs after using these codes as primary diagnoses on their claims. Coders and other home health professionals need to know that these codes are still valid and need to be used appropriately. The cause for ADRs and other medical reviews on claims with these codes as primary relates to the use of hypertension as a primary diagnosis for multiple episodes. CMS is inquiring as to whether or not these patient’s are truly unstable, or if agencies are just monitoring blood pressures for multiple episodes. Second, coding for hypertensive heart disease (402.XX) does not presume a relationship between the hypertension and heart disease. In order to use this code, the physician absolutely must state that there is a causal relationship present between the heart disease and hypertension. Furthermore, take note that only certain cardiac conditions are classified under hypertensive heart disease (402.XX), and that this does not include many conditions such as coronary artery disease.


#2) Diabetes as a primary diagnosis- the popularity of many software edits and OASIS scrubber systems has created a whole new wave of challenges for agencies and caused coders to second guess their skills. Many software systems will report an edit that Diabetes (250.00) should not be coded as a primary, as (according to the incorrect software warning) the code indicates the diabetes is “stable”. However, this is a complete falsehood and terribly misleading guidance. 250.XX indicates the diagnosis of diabetes. The fourth digit “0” indicates the physician indicated no manifestations. The fifth digit “0” indicates that the physician did not diagnose the diabetes as uncontrolled or out of controlled. Under no circumstances does the code 250.00 indicate stable Diabetes. However, agencies and coders are being misled by poorly phrased software edits. While its important only to use Diabetes without mention of complications, and not stated as uncontrolled (250.00) as a primary diagnosis when the clinical record indicates it, there is no coding guidance or regulation preventing its use.


These two misunderstandings can cause serious problems for home health coders, not to mention creating claim errors for agencies as well. As we make the transition to the ICD-10-CM code set, coders are going to need to be even more cautious in keeping their eyes and ears open for these coding falsehoods. In order to help combat some of these perplexing untruths and keep coders on the right track, we will be frequently posting here on Home Health Insight some of the more commonly encountered coding myths. Please feel free to submit your coding myth, mystery, or question to us!


Brandi Whitemyer, Guest Blogger, Senior Associate, Selman-Holman & Associates, LLC and CoDR—Coding Done Right


Are you ready for ICD-10-CM? Those attending my classes feel more confident and ready for a smooth transition. Testing claims in ICD-10-CM began April 1. Please join me in Baton Rouge April 25, Mission May 23 or San Antonio on June 26.   Check for information. Lisa

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