Posts Tagged ‘Coding Compliance’

ACOs, Transitions of Care, Patient Centered Medical Homes, Care Transitions: What Do They Mean for Home Health?

Wednesday, June 25th, 2014

ACOs, Transitions of Care, Patient Centered Medical Homes, Care Transitions: What Do They Mean for Home Health from RachelBuckleySelect

Preparing for ICD-10: More than Review Sessions for the Coders

Monday, October 21st, 2013

CMS has already identified the expectation of at least a 10% claim rejection due to incorrect codes or codes lacking in specificity.  Besides increased claim rejections, payors are predicting increased delays in processing care authorizations, slowing cash flow, and coding backlogs.

To guard against being one or several of those statistics, home health and hospice agencies must prepare now.  Agencies must plan for education and training of coders, billers, and managers, updating software and hardware, updating forms, processes, policies and procedures, and related consulting costs.

Leaders must prepare for a decline in clinical and coding productivity as well as the need for data conversion and design of new tools and resources. On the positive side, conversion to ICD-10-CM affords the agency leaders the opportunity  to conduct a comprehensive review of agency operations and to determine if contracting with an outside third party Coding agency is the best way to handle much of ICD-10-CM.

Leaders must look at who and what will be impacted at their agency and devise a strong plan.  Timelines for assessing gaps, devising interventions and tools as well as testing those items must be included in the plan.

Clinical leaders must look at what documentation may need to be expanded. What forms and processes will be impacted?  IT managers must look at system readiness not just for 5010, but for financial and clinical data conversion, reformatting of reports, as well as compliance risks.  Billing managers must look at any claims processing changes and reconciliation processes and reports. They must look at ICD-10 implementation dates, payor readiness and the ability to run dual systems for ICD-9-CM for care delivered prior to 10/1/2014 and ICD-10-CM for care delivered on and after 10/1/2014.

CFOs must look at a budget for training, education, updating of software, clinical and coding learning curves and time additions for new coding and process implementation.  They must plan for potential cash flow delays if their claims are rejected.

CEOs and COOs must look to additional personnel needs due to increased time needed for learning and for ongoing coding requirements. They must look at training and education of, not only employees, but of subcontractors and contractors as well. They should evaluate contracting with third party coding firms and determine advantages and any disadvantages. With all of the other changes impacting the industry, many agencies are deciding coding should be completed by third party experts, such as Select Data.  Leaders must appoint managers for ICD-10-CM implementation, HIPAA HITECH risk management, preparation for the new Chronic Care Management models; ACOs, Patient Centered Medical Homes, Transitional Care programs and all the program outcomes anticipated. The leaders must evaluate their internal expertise and determine if external consulting or service delivery, is needed.


Let’s look at one of the first groups to be considered for education: the intake team.

Does the intake process need to be expanded? Do the forms need to be expanded to accommodate the additional documentation required for the increased specificity necessary for ICD-10.  What are the most common diagnoses treated by the agency? What will be the needed documentation to justify assignment of those codes?

Does the team have a working knowledge of ICD-10-PCS so they may identify procedures performed in the acute care setting?

Who will be responsible for modifying forms and tools?  Does your process and/or software system require the intake team to assign a preliminary primary diagnosis? Who will be responsible for ICD-10 education for this team?


Direct Care Providers, whether they are employees or contractors should have an overview of OASIS C1 and the changes implemented.  They should have a review, if necessary, as to the meaning of the questions, the timeframes to be considered, and the resulting documentation necessary. In addition, they should have a thorough understanding of the general differences between ICD-9-CM and ICD-10-CM and the detailed requirements of ICD-10-CM.  The coding specificity depends on very detailed documentation. Presently, clinical documentation is under scrutiny by auditors. I am amazed when we perform audits for agencies throughout the country, the level of insufficient documentation present and the exposure of an agency if a RAC audit would occur.

At the very least, agencies should identify the top 20 diagnoses utilized at their firm, and identify the new codes, including the combination codes identified with each. Examples of combination codes include:

E08.21 Diabetes due to underlying condition with diabetic neuropathy
E08.341 DM due to underlying condition with severe non-proliferative diabetic retinopathy with macular edema
E08.22 DM due to an underlying condition with diabetic chronic kidney disease
E09.52  Drug/chemically induced DM with diabetic peripheral angiopathy with gangrene
E11.41 Type 2 DM with mononeuropathy

Review the agency assessment  for content detail  capability:

Does the assessment have laterality?
Does it have the depth of content and detail needed to support the potential diagnoses?
If the assessment was thoroughly completed, would it withstand a RAC auditor’s review?
What forms and tools will require modification? What about the careplan?
Should the Visit/Progress note be modified?
Are these notes outcomes driven?
What about Patient Teaching Tools?  Do they encourage patient self- engagement?
If the clinicians already have difficulty adequately documenting conditions, do you have a strategy for change?


Because the new ICD-10-CM code set is expected to cause a 10% rejection of all claims due to coding error and lack of specificity, the billing team should have a strong process in place to handle claim rejections and denials.

Does your Clinical team routinely audit records?
Does your Coding team have outside audits performed on their work product so you are reassured of the accuracy of the coding?Does your billing team have internal audits performed to evaluate process effectiveness, as well as claim accuracy and timely billing?

Obviously, order centric and coding centric processes should be in place to reduce denials. Assignment of codes must be predicated on specific documentation that has been verified by the coding specialists as a part of the client record.


ICD-10-CM has meant a HIPAA Version 5010 transition prerequisite.  It also means clinical and billing software system updates and processes. The impact to IT goes beyond the mere increase from 5 to 7 characters. It also means that the IT must be prepared for a dual system to be in place to handle ICD-9-CM claims for Starts of Care prior to 10/1/2014 and for care initiated on or after 10/1/2014.

Is your software vendor evaluating their integrated OASIS assessment tool to be certain it meets all the specificity requirements necessitated by ICD-10-CM?

From the simplest of needs: does it have laterality that allows for designation of both primary diabetic types, the three secondary types, and provide detail choices to support all types and conditions?


Have you contacted the payors for their planned readiness to test their system?
Have you communicated with your Clearinghouse?  We work with Emdeon and they have a test environment available to accept the new codes on claims. This environment will let us know rejection and acceptance of claims for specific payors.

CMS stated the new Grouper will be available in February, 2014. Then we will have a better understanding of the HHRG and case mix diagnoses of the future. One hundred seventy (170) casemix diagnoses have been proposed for removal thus far.


Well trained coding specialists improve your ability to drop high level clean claims coded to the highest level of specificity.  Well versed coding specialists can improve compliance, aid in OASIS accuracy, and improve likelihood that paid revenue remains retained revenue.

Agencies are finding that the specificity requirements of ICD-10-CM are necessitating updated courses in Anatomy, Physiology, Pathophysiology, Diagnostics, Pharmacology totaling around 50 hours. Agencies know the coding specialists will also need specific training of ICD-10-CM and should allow around 20+ hours.

Additionally, agencies must allow time for coding practice and parallel coding so the specialists see the differences and can practice for the future. Select Data will begin this process Q1 2014.


A smooth transition to ICD-10-CM with clean claims means effective planning. Your ICD-10-CM Project Team (consisting of members from all departments) should have by now completed the gap analysis for all departments, have started the coder training updates, and have  sent out the first letters to the payors requesting their ICD-10-CM status. You have or will soon have identified processes, tools, and forms impacted by ICD-10-CM and refined your project plan.

Operations should be developing the needed Operational solutions, planning, and preparing for the ongoing training for all departments. Next comes the specific strategies for implementation.

Are you on schedule? We have less than a year. Education and documentation excellence is critical.

Your cash flow and then retention of dollars derived could ultimately depend upon the clinical documentation and the quality of education and overall preparation for this major undertaking.

Educational Videos: Open Wound As A Primary Diagnosis

Monday, July 25th, 2011

Coding Compliance Open Wounds as a Primary Diagnosis

Open Wound as a Primary Diagnosis

Often we see the term open wound used as a diagnosis, especially as a primary diagnosis.  This is a vague term and should be avoided, because it will need clarification before it can be coded.  Did you know that an open wound can be referred to 10 or more different types of wounds?  And each one of these wounds has a different code or codes.

Some of these different wounds are:

  • Decubitus Ulcer
  • Diabetic Ulcer
  • Venous Stasis Ulcer
  • Normally Healing Surgical Wound
  • Post-Op Wound Infection
  • Dehisced Surgical Wound
  • Traumatic Wound
  • Burn
  • Chronic Skin Ulcer
  • Abscess

Each one of these requires as different code.  This stops the coding process until the nature and the origin and the location of the wound can be identified.  All these variables change the code or codes assigned.

Trauma wounds are caused by an outside trauma to the body and they include:

  • Gun shots
  • Avulsions
  • Lacerations
  • Punctures
  • Not surgical

Surgical wounds are never coded as a traumatic wound.  A superficial traumatic wound is not a full thickness wound and this includes:

  • Skin tears
  • Abrasions
  • Blisters

Skin tear is not coded as a traumatic wound unless it is exceptionally large or the skin flap has been lost.  Remember when you’re tempted to write open wound on that diagnosis line, please stop and consider specifically what kind of wound is this and where is its location, and put that information on the diagnosis line instead.

Educational Video: Coding Symptoms Of Disease Process

Wednesday, March 30th, 2011

Coding guild lines state that symptom codes are use only when no diagnosis classifiable or found elsewhere is documented.  In other words, if the specific condition is known, then that condition is coded.  Examples of this is seen frequently in homecare are listing and coding shortness of breath or edema along with CHF.  Only the HF should be coded, edema and shortness of breath are part of the symptomology of CHF.  Another example of inaccurate coding seen in home health is writing and coding joint pain when the patent has diagnosed osteoarthritis or rheumatoid arthritis or other arthopathies.  The pain is integral to the disease process so only the disease is coded.  The Plan-of-Care may have orders and goals to address pain management, disease process teaching and/or safety & activity restrictions.  These will relate to the diagnoses condition, therefore, a list of current symptoms is unnecessary even though the symptoms may be addressed separately in the Plan-of-Care.

Likewise in orthopedic and other surgical conditions, pain is an expected part of the post-operative picture and not coded separately.

If a diagnosis has not been established, the symptoms can be listed and coded in M1010/M1020.  Listing symptoms in M1010 is acceptable since the patient seeks care at the hospital or physicians office for symptoms and a definitive diagnosis may take time to be established.

So to refresh, symptoms of a known diagnosed condition are not to be listed as a diagnosis or coded separately, you must only code the condition that these symptoms relate to.

Coding Compliance Symptoms Of Disease Process

Face To Face Click to playCY2011 Changes Part I of III


M1010 OASIS Assessments Click To Play

Open Wound As Primary DX


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Part 2: Surveyors Prep for Survey and the New Entrance Interviews

Tuesday, March 29th, 2011

CMS has developed a new survey process for Home Health Agencies that will be effective May 1, 2011. It is data driven, patient outcome-oriented, but according to CMS, is less structured yet very process oriented.

For more detailed information, visit read the advanced copy.

Under revised survey protocols, agencies will be evaluated on a set of 34 standards, known as Level 1 standards. If the surveyor finds a deficiency on any one of the new highest priority standards, a partial extended survey will be conducted.

During that survey, the agency will be evaluated on 27 Level 2 standards. Both sets of standards fall under the nine conditions of participation. Surveyors must conduct extended surveys of all CoPs when any of the more serious condition level deficiencies are cited. Part 1 of this series outlined each CoP and where the G Tag fell; Level 1 or Level 2.

Many agency leaders are stating that it seems the new survey process has more detailed guidance to reduce surveyor inconsistency.

The survey tasks have been clearly delineated by CMS:

  • Task 1- Pre-Survey Preparation
  • Task 2- Entrance Interview
  • Task 3- Information Gathering
  • Task 4- Information Analysis
  • Task 5- Exit Conference
  • Task 6-Formation of the Statement of Deficiencies

Pre-Survey Preparation

Surveyors will prepare for surveys, more indepthly, using OASIS data, previous survey findings, and complaints filed.  Available OASIS reports can be generated for specific time periods, as requested, from the OASIS Coordinator’s office. These reports include case-mix, potentially avoidable events, risk adjusted outcomes based quality improvement (OBQI) or process measure reports.

OBQM Potentially Avoidable Events Report

Know that before coming to the home health agency, the surveyor will have reviewed the most recent quarter of OASIS data to identify patients with emergent care as a result of a fall at home or emergent care for wound infection or deteriorating wound status. This is a Tier 1 event. There are six Tier 2 Potentially Avoidable Events for consideration. To reach the threshold there must be patients who experienced the event and/or the agency to be surveyed must have a current incidence rate equal to or greater than twice the reference rate (Appendix B p.12)

OBQI Outcome Report

Surveyors will also review the agency’s Risk-adjusted Outcomes Report prior to survey. CMS instructs surveyors : “During the onsite survey, select patient records and home visits that focus on the outcomes identified on the OBQI report meeting the individual investigation thresholds” (Appendix B. p12).  If none of the ten listed outcomes trigger the selection criteria, another outcome should be selected from the OBQI report (that meets the selection criteria).

Patient/Agency Characteristics Report

As part of the pre survey process, the surveyor will look at this report for the same timeframe as the OBQI Outcome Report and focus on acute conditions and home care diagnoses that are statistically significant or are equal to or greater than 15% points higher than the reference rate. The surveyor is to choose up to three diagnoses or conditions that meet the criteria and look at corresponding patient records.

Error Summary Report by HHA

Surveyors will be looking for several inconsistencies and errors, such as  inconsistent M0090 date and incorrect record sequence. The latter error could trigger further record reviews if the HHA’s percent of assessments with this error in or above 10%.

What Can an Agency Do on an Ongoing Basis?

Routinely, agencies should be reviewing the online OASIS reports and identifying areas for improvement. They should show interventions planned and implementation of the plan. The agency should also reflect follow up to implementation. This practice establishes a commitment to Quality Improvement and seeking proactive interventions for areas such as recurring hospital admissions.

Part 3: Entrance Interview

CMS remains detailed as to activities that are to be included in the entrance interview.  This interview sets the tone for the survey process identifying expectations. We will explore those in the next article.