The Final Rule that was published November 8, 2012, will implement several changes beginning on January 1, 2013. Among these changes are:
- Limitation of resolved conditions that can be coded in M1024
- Clarification of Face to Face Encounter Guidelines
- Therapy
- Permanent cap of outliers
- Updates to HHPPS
- Sanctions to impose if home health agencies are out of compliance
This is the first in a series of articles that will address the coding changes for M1024.
Information from the Center for Medicare and Medicaid Services (CMS) indicate that because Medicare Home Health expenditures have increased dramatically from $10.1 billion in 2003 to $18.6 billion in 2011 (84%), the Government conducted studies to assess overall case mix versus real case mix. According to Medicare the results indicated a reduction in PPS rates. These changes in PPS rates will result in 0.01% or $10 million decrease in Medicare payments to Home Health agencies in fiscal year 2013. For more information regarding the formulas and adjustments resulting in this change, go to CMS’s website and search for CMS-1358-F.
One of the biggest factors in decreasing reimbursement is a new limitation of codes for resolved conditions in M1024 (Column 3 of the M1020 and 1022 section). The Final Rule states that agencies can no longer use resolved conditions in 1024 when using a V code that replaces a case-mix diagnosis, except for fracture codes. Previous guidance per Medicare’s Attachment D allowed and directed agencies to use resolved conditions in MO1024 when a V-code replaced the case mix diagnosis that caused the reason for home health care.
For example, before January 1, 2013, agencies were to use V58.42 (Aftercare following surgery for neoplasm) to document the reason for seeing a patient in M1020. We would then code the underlying condition that resulted in surgery in column 3, M1024. In this scenario we would perhaps use 150.1 (malignant neoplasm of thoracic esophagus) in M1024 to capture the points lost when we had to use the V code in M1020.
Beginning January 1, 2013 agencies will no longer be allowed to use diagnoses codes in M1024 for diseases that have been resolved, except for fractures codes in combination with V codes in M1020 for aftercare due to fractures, to capture case mix points. This will result in decreased revenues for most agencies who have been coding M1020, M1022, and M1024 correctly in the past.
Other coding guidelines are to be followed as stated previously. This means agencies are to continue coding the primary reason for home health care in M1020, followed by other diagnoses and co-morbid conditions that are being treated and/or must be reported per Medicare and Coding Clinic guidelines. Attempts to manipulate diagnoses or the order thereof to increase revenues rather than to report the appropriate reasons for home care would be considered “upcoding” and should be avoided.
According to NAHC, the following ICD-9 codes will no longer be viable codes to use in M1024 when removed by surgery:
ICD-9 Codes 140-149: Malignant Neoplasms of Lip, Oral Cavity, and Pharynx
150-159: Malignant Neoplasms of Digestive Organs and Peritoneum
160-165: Malignant Neoplasm of Respiratory and Intrathoracic Organs
170-176: Malignant Neoplasm of Bone, Connective Tissue, Skin, ad Breast
179-189: Malignant Neoplasm of Genitourinary Organs
190-199: Malignant Neoplasm of Other and Unspecified Sites
213-234: Benign Neoplasms (those listed in this section)
320-326: Inflammatory Diseases of the Central Nervous System
327: Organic Sleep Disorders
414: Chronic Ischemic Heart Diseases (Coronary Atherosclerosis, Aneurysms and so on)
440: Atherosclerosis
530-539: Diseases of Esophagus, Stomach, and Duodenum
540-543: Appendicitis
550-553: Hernia of Abdominal Cavity
555-558: non-Infective Enteritis and Colitis
560-562: Intestinal Obstructions, Diverticulas
564-567: Functional Digestive Disorders, Abscesses, Peritonitis and Peritoneal Infections
569: Other Disorders of the Intestines
570: Acute and Subacute Necrosis of the Liver
574-577: Cholelithiasis and disorders of the Gallbladder
685: Pilonidal Cyst
707: Ulcers/Pressure Ulcers
711: Arthropathy associated with infections
713: Crystal Arthropathies
715: Osteoarthrosis
716: Other and Unspecified Arthropathies
720-724: Dorsopathies
726-727: Rheumatism, excluding the back
730: Osteomyelitis, Peritonitis and Other Infections Involving Bone
731: Osteitis deformans and osteopathies associated with other disorders classified elsewhere
733: Other disorders of bone and cartilage (osteoporosis and pathologic fractures are in this subclass)
741: Spina Bifida
785: Symptoms involving the cardiac system
831-838: Dislocations of joints
A correct scenario for coding fractures after January 1, 2013 would be: M1020a V54.25: Aftercare for healing pathologic fracture of upper leg; M1024: 733.15 Pathologic fracture of other part of femur; M1022b: Osteoporosis, Unspecified, 733.00.
Agencies and staff should continue to focus on adequate assessments on admission and recertification, as well as resumption of care following an inpatient stay in order to deduce what diseases or conditions require the most care by the agency. Physician query should be practiced when patients or caregivers are unable to voice a thorough or correct patient history. These details will give agencies the needed information to code properly and capture all case-mix points due them and assist in securing the maximum episode payments legally due them. As we approach ICD-10 implementation and pay for performance, these skills will be all the more important.
REFERENCES:
Decision Heath Complete Home Health ICD-9-CM Diagnosis Coding Manual, 2013 edition (www.decisionhealth.com/store)
