In the home health industry, coding on the OASIS, the Plan of Care, and the Claim must match and must comply with ICD-9-CM coding guidelines. Incorrect coding and sequencing has been a concern of CMS for several years; and Home Health Agencies have had multiple opportunities to conform to the established rules and guidelines. Because this new edit has the potential to hold up claims processing in the near future, agencies should ensure that their coding is compliant.
On August 1, the Centers for Medicare & Medicaid Services (CMS) announced an edit to home health claims submitted beginning January 1, 2015. This edit is to ensure that principal diagnoses reported on the home health claim are appropriate according to coding guidelines for ICD-9-CM.
ICD-9-CM coding will continue to be in effect from January 1, 2015 through September 30, 2015. CMS states that “home health agencies are to report diagnosis codes on their home health claims as required by ICD-9-CM coding guidelines.”[1]
Adherence to these guidelines when assigning diagnosis codes is required under HIPAA. According to official Coding Guidelines and Attachment D of the OASIS Training Manual, the primary diagnosis is defined as the focus of care for the episode’s home health plan of care. [2]&[3]
Attachment D states:
- HHA clinicians/coders are expected to comply with ICD-9-CM coding guidelines when assigning primary and secondary diagnoses.
- If the diagnosis code is not compliant with ICD-9-CM sequencing requirements, then it must not be reported on the OASIS.
If a condition under consideration calls for multiple diagnosis coding (such as an etiology or manifestation code pairing) and the guidelines for coding and sequencing for these pairings are not followed, the codes are not valid. Upon analysis of OASIS (Outcome Assessment Information Set) records and claims for fiscal year (FY) 2011, CMS noted that some agencies were not complying with coding guidelines when reporting the primary diagnosis, in particular with codes that require the underlying condition be listed first, followed by the manifestation code.
There are several ways to ensure compliance. One way to ensure compliance is to have certified coders working with the agency. If the agency is outsourcing, make sure to use contracted certified coders who will keep the agency compliant. Finally, make sure all agency software is up-to-date with the latest coding guidelines. Prompt attention to coding compliance, starting with a coding audit well before January 1, 2015, will ensure that agency claims are processed timely.
[1] http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1405OTN.pdf
[2] http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/OASIS_Attachment_D_Guidance.html
