Posts Tagged ‘Home Care Coding’

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.

The Patient Care Medical Model and Guided Care: Home Health Collaboration

Friday, June 1st, 2012


  • As a percentage of GDP, health care expenditures are about 18%. By 2019, the national health care expenditures will be 19.3% and approaching an unsustainable level.
  • CMS states: Innovative approaches to quality healthcare must be found.

New Models of Care are mandated under the Patient Protection and Affordable Care Act (PPACA) as well as naturally occurring.

CMS has identified “Triple Aim” Goals

  1. Better Health for the Population
  2. Better Care for Individuals
  3. Lower Cost through Improvement of Care Delivery

CMS motivates with:

  1. Incentive Programs: With Quality Reporting through approved programs and EHR incentives
  2. Payment Policies: With Accountable Care Organizations and innovative programs such as Patient-Centered Medical Homes and solid Care Transition Programs
  3. Quality Programs: The Programs will truly partner with the patient and Quality Care Organizations

CMS states care presently is usually:

  • Uncoordinated- poor medication management, poor preventive care and overall strategies, unreliable information transfer, who to call for what?
  • Unsupported- lacking standard and known process, unsupported patient activation transfer
  • Unsustainable- no comment needed

Health Care delivery is changing fast. Old Medicare models in home health are being moved aside. Are you ready for Care Transitions, Patient Care Medical Models, and Guided Care?  Should you be a collaborative partner with other healthcare sectors? Are you ready to assume some financial risk in a collaborative venture? There are many new innovative projects underway. Two of those new concepts include the Patent Care Medical Model with Guided Care by the Physician and RN. How would your home health agency participate in this new health care delivery process?

CMS states the Patient Care Medical Model (PCMM) rests on five pillars:

  1. Patient-centered orientation directed toward their unique needs, culture, values, and preferences.
  2. Comprehensive, team-based care that meets the majority of each patient’s physical and mental health needs.
  3. Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
  4. Superb access to care.
  5. A system approach to quality and safety including Care Management Interventions.

Selecting Care Management Interventions include:

CMS suggests discussing many provider and system interventions

Evidence-based Guidelines and Protocols

Provider Education

Practice-site Improvement

Provider Profiling and Reports

Provider Incentives

Registries and Clinical Information Systems


Electronic Medical Records, Decision Support Reminder System, and Other Electronic Communication Systems

Educational Brochures and Member Letters

In-Person Care Management

Call Center

Self-Management Education

Self-Monitoring Devices

The Patient Care Medical Home (PCMH)

“The PCMH is intended to result in more personalized, coordinated, effective, and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location by:

  • Taking collective responsibility for patient care
  • Providing for the patient’s health care needs; and
  • Arranging for appropriate care with other qualified


The Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare

  • Requires an interdisciplinary team to take responsibility to improve access, continuity, and coordination of care
  • Patients and family members are engaged through education and supporting self-care and disease management
  • The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person.

This program is comprehensive, team based primary care for reducing cost geared toward a collaborative model, easy to implement, capable of providing excellent care to patients with multiple chronic conditions.

Using Guided Care in this Model


  • Specially trained RNs based in the PCMH physician offices.
  • The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions.
  • The nurse and her “back-up” RN partners with the patient for the rest of the patient’s life.

This model was initiated in 2002 by John Hopkins University.


The RN will converse, assess, and create an evidence-based Care Guide (notice they chose “guide” not “plan”).

The Guided Care RN coordinates care with other care providers, HH providers, clinics, and hospitals.

The Guided Care RN educates and supports family and caregivers.

This RN also identifies community services that are most appropriate for this patient and her needs.


Physicians planning Guided Care Can receive:


Free Technical assistance at:

Online courses from John Hopkins Nursing available for RNs,

There are also Physician and family courses

Order the free Implementation Manual:

Guided Care: A New Nurse-Physician Partnership in Chronic Care

There are also free books and material for families.

Guided Care is

A collaborative approach, physician directed-Nurse assisted, that truly works with the patient to achieve education, accomplish goals, and allieve anxiety from lack of continuity

A proven evidence based team approach that includes care planning, care transition, education, and support

Look at Kaiser

Look at Vanguard Medical Associates

Piedmont Community Health Plan


Home Health Agencies Interested in Collaboration


Look for innovative partnerships

Offer same day access and response

Look at creative tools needed; specialized programs.

Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs.

Find consistent communication methods and processes.

Establish proactive, prepared, practice teams.

Be willing to break away from the traditional Medicare model of care.

Consider shared risk.


Home Health Agencies should


Be willing and available of leadership and clinicians to “up-skill.” Be flexible. Be rapid in response.

Be willing to work COLLABORATIVELY.

Agree to have certain clinicians trained in PCMH constructs.

The HH agency should see improvements in goals attained.

The HHCAHPs should reflect the patient satisfaction.


New Innovations and New Types of Care Delivery


Together we can invent and create our way to success.  We can work together for a individualized, sustainable, proud new American Health Care System. Better care is overall less costly care. No matter how we view the new models, they are going to augment and eventually could replace the present model. Your thoughts?



ICD-10 CM is Delayed but NOT for Long Because We Cannot Wait

Monday, April 30th, 2012

HHS proposes a one-year delay of ICD-10 compliance date.

On April 17, 2012 the Department of Health and Human Services (HHS) published a proposed rule that would delay, from October 1, 2013 to October 1, 2014, the compliance date for the International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).

Per the CMS website, “The ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OESS is part of the Centers for Medicare & Medicaid Services (CMS).”

HHS states that covered entities must be in compliance with ICD-10 on October 1, 2014. The statement was made that providers required the extra year to be adequately prepared for the transition.

Providers have outgrown the present ICD-9 CM system. That system is over 30 years old, implemented in 1979 and has no more room to handle needed codes for new medical conditions or technological advances. It is not always precise or unambiguous. Because the classification system is organized with specificity, each three-digit category can have only 10 subcategories and most of those numbers already have assigned diagnoses.

The ICD was developed in the late 1800s to collect data regarding mortality causes and rates. It is an international classification system endorsed by the World Health Organization (WHO) in 1994 and started to be used by WHO members in 1994. The WHO updates the classification usually every 10 years and is looking to beta test ICD- 11 next year.

ICD-10 is already being utilized in Asia, most of Europe and all of Canada and Australia enabling those 99 nations to share public health data. Implementing ICD-10 effective October 1, 2014 allows the USA to be aligned with those nations. ICD 10 is also available in 36 languages including English, Chinese, Arabic, Russian, and the Romance languages: French and Spanish. Improved clinically coded data is essential in this modern era.


Uses of the Clinically Coded Data

  • Benchmarking and quality measurement: to improve quality and effectiveness of patient care
  • Making clinical, financial, funding, expansion, and education decisions
  • Healthcare policy
  • Public health surveillance (increase ability to track and intervene if global health threats)
  • Reimbursement
  • Research- code analysis is crucial to research
  • Increased specificity in data means more robust design of algorithms to predict outcomes and care
  • Increased coding detail offers capability to find previously unrecognized relationships of diseases and variables

Why ICD-10-CM

  • Bring US in alignment with worldwide coding system
  • Greater coding specificity and accuracy with “full code definitions”
  • Increased capability to measure healthcare quality, safety, and efficiency.
  • Lower Costs through increased efficiencies
  • Decreased reduction in additional information sent to payors
  • Synergistic effects with the Electronic Health Record (EHR)
  • Clearer recognition of medical advances
  • Clearer recognition of technological advances

ICD-10 and better data for QI

  • Decrease in complications and improved patient safety
  • Improved patient outcomes
  • Improved ability to reassure outcome efficiency and costs

There is also improved capability to determine disease severity for audit risk adjustment.

Benefits of ICD-10 CM

Organizational Monitoring

  • Administrative efficiencies
  • Cost containment
  • More accurate trend and cost analysis as well as analyze trend and cost data

Improved coding accuracy and productivity


  • Increased accuracy
  • Fairer reimbursement
  • Improved justification for medical necessity
  • Fewer errors and rejected claims

Reduced opportunities for fraud

  • To handle the complexities and shear size of the number of codes ICD-10

requires expertise in


physiology, and


  • Besides moving from 13,000 codes to 68,000 available codes
  • ICD-10 allows laterality and bilaterality

ICD-10 specificity improves coding accuracy and richness of data for analysis

The Coding specificity is far greater than ICD-9-CM and the need to better understand A&P and diagnostics is vital. Improved education for coding specialists is necessary.

A Sample Coding Preparation Plan: Phase 1

  • 2012-2013…Assess for coder gaps

as to body system anatomy 15 hrs

as to body system physiology 15 hrs

as to diagnostics/pathophysiology 20 hrs

as to diagnostics/pharmacology 20 hrs

as to medical terminology 10 hrs

A Sample Coding Preparation Plan: Phase 2

  • Organizational leaders need to assess their

Organizational readiness: forms, clinical software, documentation readiness

- Billing/Support system needs

- EHR system

- Support systems

- Case management processes

- Disease management

- Compliance software

A Sample Coding Preparation Plan: Phase 3

There needs to be:

  • Testing of Coding by parallel Coding  ICD-9 and ICD-10 CM
  • Testing of Billing System for smooth transition
  • Look for misinterpretation by auditors/payors

Be certain everyone has past training goals i.e. understands documentation of medical necessity to code

Sample Coding Preparation Plan: Phase 4

  • Go Live
  • Evaluate processes
  • Evaluate Coding
  • Evaluate Billing

In Phase 1 there is a need to fully review each body system.

  • Choose 2-3 body systems for assessment of need such as:
  • Cardiovascular System

Identify the Anatomy and Physiology of the heart. Prepare pre/post tests.

Identify the Anatomy of the circulatory system and the role of each vessel type

Review categories 100-109 in ICD-10-CM Chapter 9, “Diseases of the Circulatory System.”

  • Explain ICD-10-CM terminology related to diseases of the circulatory system
  • Create scenarios and have coding team gatherings where learning can be fun

These scenarios will allow you to assess gaps and needs

  • Consider use of webinars
  • AHIMA or like courses
  • Online self study may fit certain lifestyles better
  • Have videos/PowerPoints of body systems available

Look at workshops, seminars, lunch and learn sessions

Each body system should be reviewed, such as below:

  • The Heart
    • Has three layers:  endocardium, myocardium, and epicardium
      • Endocardium – membrane lining interior wall
      • Myocardium – thick, middle, muscular layer
      • Epicardium – thin outer layer
  • Pericardium – 3 layer sac that surrounds and protects the heart
  • Route of Blood Flow Through the Heart
    • Blood enters the right atrium from the inferior and superior vena cavas (veins)
    • Blood leaves the right atrium to the right ventricle through the tricuspid valve
    • Blood leaves the right ventricle through the pulmonary semilunar valve to the pulmonary artery to the lungs

Unoxygenated blood

  • Route of Blood Flow Through the Heart
    • Blood leaves the lungs via the pulmonary veins to the left atrium
      • Oxygenated blood
  • Blood leaves the left atrium through the mitral valve to the left ventricle
  • Blood leaves the left ventricle through the aortic semilunar valve out to the body
  • A series of 20-30 slides could be developed to review the Cardiovascular System

These types of reviews could be excellent resources also for specific component answers such as Cardiac conduction

  • Route of Blood Flow Through the Heart
    • Blood leaves the lungs via the pulmonary veins to the left atrium
      • Oxygenated blood
  • Blood leaves the left atrium through the mitral valve to the left ventricle

Blood leaves the left ventricle through the aortic semilunar valve out to the body

  • Cardiac Conduction
    • Sinoatrial node (SA node, called the pacemaker of the heart) à Atrioventricular node (AV node) à Bundle of His à right and left bundle branches à Purkinje fibers

SA node (pacemaker) is located in the upper part of the right atrium below opening of the superior vena cava

  • Discuss disease processes such as:



Heart Failure

Use specific terms and processes in the discussions

  • Discuss diagnostic and intervention procedures as well as pharmacology
  • Have teams participate in establishing education plan after gaps have been identified
  • Make certain some kind of training takes place each month, even if it is only a memo about a specific aspect of ICD-10

Keep ICD-10 in front of everyone. Remember, you only have until 2014. Let’s get started!

The New Survey Protocols: Are You Ready or How Did You Do?

Tuesday, January 31st, 2012

The CMS new survey protocols have been in effect for over six months. The revised Home Health Agency Survey Protocols and New State Operations Manual are available online. The new survey process is data-driven and patient outcome-oriented with a focus on patient visits and personnel interviews. Though it appears less structured, it is very process-driven.


The new tiered system directs surveyors to focus on quality of care. A detailed list of surveyor probes are provided, outlining questions that may be asked throughout the survey process. Agencies should review the questions outlined for surveyors in order to prepare for the survey process. Preparation for this process will reinforce other patient focused processes. Are you ready? Visit to read more.


CMS stated surveyors would cite more deficiencies under the new process. After one year, it will be interesting to view the stats.


The Key Focus Areas

Patient Rights


Plan of Care

Outcomes and Improvement

Infection Control


The survey process is guided by interpretive guidelines and survey protocols established to provide guidance for surveyors. The surveyor will review the assessment, the medication profile, and physician orders and then evaluate the established plan of care with review of that implementation of the plan of care. Patient and personnel interviews should support the findings of the clinical record.  Prepare personnel for survey interviews so they are familiar with terminology and types of questions they may be asked. Support the interviewees by having them understand that they are the experts in care delivery. They are merely verbalizing the assessment, the care, and the outcomes expected or achieved.

All surveyors are required, by CMS, to utilize these guidelines when evaluating an agency as to compliance with Federal regulation. Remember, the guidelines do not replace regulation and are not allowed to be the basis of any citation, but they provide guidance.  Violations are to be based upon clinical record reviews, interviews with patients, caregivers, and personnel, as well as the agency’s practices in relationship to regulation and agency policies.

“The survey and certification process provides a method for CMS to evaluate HHA compliance with the Conditions of Participation (CoPs), ensuring that patient services provided meet minimum health and safety standards and a basic level of quality. The HHA survey process incorporates an approach that is patient-focused, outcome-oriented and data-driven making it more efficient and effective in assessing, monitoring, and evaluating the quality of care delivered by an HHA…” (Appendix B, p.6).

The surveys are required to have at least one RN on the team.  Surveyors are required to attend the HHA Training Course prior to any survey. They are then required to be in an observational role as part of the training.

Preparing for the Survey


Appoint at least one person, in your agency, to become very familiar with the new survey process. You may want that person to be OASIS certified to readily discuss OASIS conventions. Develop a thorough process-oriented clinical orientation. Be certain all policies and procedures are current and personnel have had the appropriate inservices.

Have a third party or internal coding expert available to answer any questions regarding diagnoses coding conventions, manifestations, and sequencing. A coding audit by an external review agency may give you some peace of mind.

Be certain your clinical lead has reviewed and audited Starts of Care, Resumptions of Care, Recertifications, and Discharges. Be certain the assessments are well documented and the care plans adequately support that proposed Plan of Care.

Be certain the billing (revenue cycle management) audits include the compliance processes that prevent inappropriate billing without a physician order and evidence of all detailed and signed visit notes.

Types of Surveys

The survey process provides for a standard survey, a partial extended survey, and an extended survey. All HHAs must undergo a standard survey.

Initial Certification

The initial certification requires compliance with SS Act 1861(0) (4) as well as 2180 regarding licensing requirements. In addition, follow the guidelines of SS2008 “Early Surveys of New Providers and Suppliers”.

The State Agency (SA) surveyor or the National Accrediting Organization (AO) inclusive of Joint Commission, CHAP, or ACHC with deeming authority conducts the initial certification. At the time of that survey, the HHA must

  • Be operational and have completed the Medicare Enrollment 855A verified by the assigned MAC.
  • Provide nursing and one other therapeutic service (42 CFR 484.14(a).
  • Meet the new capitalization requirements and have completed an OASIS test submission.
  • Have provided care to a minimum of 10 patients requiring SKILLED care.

Standard Survey

This survey is to be a review of the quality of care and services furnished by the HHA as measured by the medical, nursing, and rehabilitative care indicators. The new changes require this survey to review compliance with regulations most related to high-quality patient care. These highest priority standards (regulations) are called Level 1 standards addressing 9 of the 15 CoPs. The thinking is thatif the agency is in compliance with these standards, it is in compliance with all CoPs.

Therefore,  “the surveyor can make a determination  that the HHA is in compliance with all CoPs when, after a review of the Level 1 standards, and after completing the required clinical record reviews, home visits, and interviews with patients and HHA staff, he/she does not discover any findings which would support a deficiency citation.”

Partial Extended Survey

This survey occurs when a standard level survey identifies a non compliant Level 1 standard and/or a deficiency practice may exist at a standard or conditional level not examined at the standard survey.  During this survey, the surveyor reviews at a minimum, the Level 2 standards under the same condition which are related to the non compliant Level 1 standards. See Table 1 Level 1 and Level 2 Standards.

Extended Survey

This survey includes a review of all conditions. It may be conducted at any time at the discretion of CMS and is required to be conducted when any conditional level deficiency is identified. The surveyor is required to review all agency policies, procedures, and practices related to the substandard care (one or more condition –level deficiencies).

Recertification Survey

All HHAs are mandated (SS1891) to have a recertification performed no later than 36 months from a previous recertification survey. These surveys are standard unless a Level 1 citation is leveled.

Now, you know the types of surveys. The following chart lists the standard and partially extended surveys with their related priority standards and G-tags. The more you know about the new process, the better prepared you will be for your next survey.

Level 1 and Level 2 Standards Appendix B

Table 1

Conditions                            Standard Survey                Partial Extended Survey

Level 1                                   Level 2


Patient Rights                          G107, G109                             G101, G108, G111, G114


Compliance with                     G121                                        G118

Federal, State, Local


484.14 Organization,               G123, G133, G143,                 G124, G125, G127, G138,

Services and                             G144                                       G139, G150


484.18 Acceptance                 G157, G158, G159                      G160, G162, G163

Of Patients, Plan of Care,       G164, G165, G166

Medical Supervision

484.30 Skilled                          G170, G172, G173,                     G169, G179

Nursing Services                     G174, G175, G176,


484.32 Therapy                        G186, G187, G188                      G190, G193

484.36 Home Health Aide      G224, G229                               G212, G215, G225, G226, G230

Services                                                                                     G232

484.48 Clinical Records          G236                                        G239

484.55 Comprehensive          G331, G332, G334,                  G339, G341

Assessment of Patients          G445, G336, G337,

G338, G340

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.