As a young home health nurse, I was blessed with a mentor and friend who was a QA specialist and expert coder.  Ms. Kay and I worked for the largest home health agency in middle Tennessee at the time, and with Kay’s mentorship, I learned how to take my patient’s assessment and physicians’ documentation to paint diagnostic picture of what the focus of care would be for the episode. While diagnosis coding can seem a bit overwhelming to those who have little or no experience, I am sure that with education and mentoring, you too can learn to code in the home health setting.

Let’s start with some basics:

1. Be sure you have access to a current copy of the ICD-9-CM code book. Code books generally change yearly in October and new code books come out about this time yearly. The code book I use is Decision Health’s Complete Home Health ICD-9-CM Diagnosis Coding Manual.[1] I prefer this code book because it is comprehensive and includes scenarios at the end of each chapter with coding examples. These books can be purchased at store.decisionhealth.com.

2. Learn what the icons in your code book look like. For example, manifestation codes, case-mix codes and case-mix manifestation codes, hospice icons, and icons indicating need for required 4^th and 5^th digits are important to understand in home health. Find these in your code book and learn what they mean. Also learn what the abbreviations mean, such as NEC (not elsewhere classified), and NOS (not otherwise specified).

3. Remember to obtain as much information as possible from the patient and patient’s family regarding their illnesses. Be sure you find out when each illness was diagnosed or last treated and by whom. This is valuable information you will use when coding, or to query the physician(s) for more information.

4. Document the locations of any wounds, fractures, lesions, accidents or injuries, using the most specific terminology possible. This is important in ICD-9-CM, but will be required much more specifically in ICD-10-CM. For example, if the patient has a CVA, you will need to know what part of the brain the CVA occurred as well as what type of CVA occurred.

5. Review your documentation and find what the reason(s) for home health care are for the episode. These issues, as well as any co-morbid conditions required by Medicare and coding clinic guidelines are what you will be assigning codes for. Keep in mind the frequencies of each discipline when you are deciding your primary focus. Remember the codes must match on the 485 Plan of Care and the OASIS, and that documentation supports these diagnoses.

6. Always start coding by looking in the alphabetical index of conditions first, known as Volume 2 in the code book. The alphabetical listing contains clues and instructions that are very important when going on to the next step. Once you find the code in the alphabetical index, jot this number down and move to the next step.

7. ALWAYS look the diagnosis code up in the alphabetical index, AS WELL AS the tabular list of diseases broken down in chapters by system. This tabular list is known as Chapter 1. It is imperative that you complete both steps, no matter how experienced a coder you may be. Each view gives you valuable and necessary rules and exclusions that must be followed when coding. For example, in manifestation code scenarios, the directions may state “code underlying condition first”.

8. Learn and pay attention to the Instructional Notations, such as INCLUDES and EXCLUDES. These notes are found immediately under the three digit code and give further definition or guidelines when using the code.

9. If you are coding procedures, first look at the end of the book, Chapter 3. As before, once you find the number in the alphabetical index, be sure you go on and look up the procedure code in the tabular listing that follows.

10. Avoid using NOS codes as much as possible. Remember, if you are doing a comprehensive assessment, you should know the where and how needed to code properly.

11. Work with your Director of QA and or Director of Nursing when learning to code. Let them know you are interested in learning, and that you will be submitting coding for review. Welcome their feedback and instruction as you learn.

12. NEVER, NEVER, NEVER code just from memory. This is a rule that I follow and has been proven to help avoid costly mistakes. No matter how convinced you are that you are right, be sure to check those digits.

13. Code the condition that you will be treating primarily first, followed by all other diseases/conditions you are treating. Then code any co-morbid conditions that will influence the patient’s progression: Diabetes, CHF, COPD, HTN, and so on. Remember, if nursing is once a week, and therapy is going 2-3 times a week, you will probably code the condition the therapist is treating first.

14. Avoid assigning codes for symptoms that are directly related to a disease you have coded. For example, do not code edema with CHF or shortness of breath with COPD codes.

15. Remember that new codes are added and deleted to the case-mix list and the diagnosis code listing yearly. This is why it is imperative that you use a current year’s code book beginning in October of the year. (This is why I am using a 2013 book already).

16. Practice, practice, practice. Code your patient’s admissions, recerts, and resumptions of care. Let your supervisor check your work. Read the scenarios listed in your code book as you learn.

Don’t be afraid to make mistakes. At first the process will be a bit disjointed and feel awkward. However, as you gain experience with the basics of coding for home health, you will soon be comfortable with using the code book and will be ready to move on to more advanced coding practices.

References:

Centers for Medicare & Medicaid Services  (www.cms.gov)

Association of Home Care Coding & Compliance (ahcc.decisionhealth.com)

Home Health Insight (selmanholmanblog.com)

Centers for Disease Control and Prevention (cdc.gov)