Showing posts tagged with: Home Care Coding

Prepping for PDGM

Clinical Practices, Coding, Payment Rate Updates, PDGM

Prepping for PDGM

PPS final rule increases agencies' payments for 2019, finalizes PDGM

Now in the third week of January, 2019 and the PDGM model will be here in less than a year. Medicare-certified home care agencies need to begin NOW to prepare for the 2020 transition to a Patient-Driven Groupings Model. The proposed PDGM model, required by the Bipartisan Budget Act of 2018, is intended to remove current incentives to over-provide therapy services and changes the 60-day episode of care unit of payment to 30 days according to CMS. Also, a new set of groupings for the patient – diagnosis and functional levels – will be introduced that determines the patient’s reimbursement for the new 30-day episode. The PDGM model is planned for implementation on January 1, 2020 (Harris, 2018). Home care agencies should focus on several areas within their agency in order to prepare for PDGM. The fits area of concern should be the referral systems. According to Home Health Care News' Kaitlyn Mattson, "CMS’ move to shake up case mix specifically in regard to referral source is, at least in part, due to data and the agency’s belief that patients coming from institutional settings are typically sicker and, thus, need more care and resources." Moreover, "“60% of referrals come from the community,” Gina Mazza, director of the regulatory and compliance division at Fazzi Associates, told HHCN. “Every agency needs to understand how they specifically will be impacted by this new payment model. This is an area agencies really need to think about—what’s my patient population look like? Where do my referrals come from? Are there opportunities for me to make any changes?” Mazza added, “Referral source is always an area agencies want to work on, cultivate” (Mattson, 2018). Another area is staff education which is key to smoother PDGM transitions. Supporting on-the-ground staff may be the key to an easier PDGM transition. “Having the resources available to do the education—to stay on top of making sure nurses understand and are able to still spend the amount of time they want with their patients while fulfilling all the new requirements [will be paramount],” Susan Adams, vice president and administrator at Masonicare Home Health and Hospice (Mattson, 2018). Now finalized by CMS, there will be a learning curve with PDGM until staff becomes more comfortable with the intricacies of the rule. Agencies need to set aside a significant amount of time and attention so they can work with staff, so that assessments and documentations are really tight, Joy M. Cameron, vice president of policy and innovation at ElevatingHom said (Mattson, 2018). Confused? Frustrated? Not sure where to begin prepping for PDGM? Don't worry. SelectData has you covered. Contact our Business Development team to find out how SelectData can help you smoothly transition into PDGM today! Call 800-332-0555 or email and ask about our PDGM solution today! Resources Harris, T. (2018). OASIS-D GG0100B OASIS Home Health - Prior Mobility Functioning and Physical Therapy. Home Health Blogger. Retrieved from: Mattson, K. (2018). PDGM Likely to Shake Up Patient Populations for Home Health Agencies. Home Health Care News. Retrieved from:

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New ICD-10 Code Updates: Ask the Right Questions to Get the Right Code

Clinical Documentation Improvement, Clinical Practices, Coding, Healthcare, ICD-10 CM, OASIS-C2, Uncategorized

New ICD-10 Code Updates: Ask the Right Questions to Get the Right Code

CMS releases updates to the ICD-10-CM coding manual

Every October, the CDC and CMS release updates to the ICD-10-CM coding manual. These updates include both codes in the tabular and alphabetical indexes as well as official guideline changes. The following is a summary of some of those changes that Home Health Agencies need to know about.
  • Non-pressure ulcers now have 3 new code subcategories to include those ulcers that are down to the muscle or bone but do not have necrosis and for those ulcers that have tendon/ligaments showing. The clinician should always document the severity of the non-pressure ulcer in terms of skin breakdown, fatty layer, muscle exposed, muscle exposed with necrosis, bone exposed, bone exposed with necrosis, or other appropriate descriptive terms (tendon/ligament, hard eschar, slough obscuring wound bed, etc.).
  • C Diff is now being captured as being recurrent or not stated as being recurrent. Recurrence is defined by complete resolution of C diff symptoms while on appropriate therapy, followed by subsequent return of diarrhea and other symptoms after treatment has been stopped. Recurrence usually occurs within one week after treatment stops but may happen up to 8 weeks later. The physician would need to confirm whether C diff is recurrent or not.
  • Types of myocardial infarctions now play a role in determining the appropriate ICD-10 code. Type 1 is the most common MI which is associated with ischemia and due to primary coronary even. Type 2 MI is due to imbalance in supply and demand of oxygen. Type 3, (which we wouldn’t see in home health), is sudden cardiac death, including cardiac arrest. Type 4 MIs are associated with percutaneous coronary intervention while type 5 MIs are associated with a CABG procedure.
  • Secondary pulmonary hypertension diagnosis code has been further detailed to describe what the condition is that is causing the secondary pulmonary hypertension, including left heart disease, lung disease, etc.
  • Lumbar stenosis should be classified with or without neurogenic claudication. Neurogenic claudication is leg pain with walking. The physician must confirm neurogenic claudication for it to be coded.
  • Bowel obstructions can now be captured as complete or incomplete/partial. Complete bowel obstructions would need surgery to correct while incomplete/partial bowel obstructions can be sent home for it to resolve. The coding specialists need to know whether a bowel obstruction is resolved upon discharge from the hospital. Resolved conditions cannot be coded in home health except for in OASIS items M1011 and M1017 when they reflect the patient’s recent history.
  • New coding guidelines state that if a patient’s visual category is not documented then coding specialists can only code unqualified visual loss. It would be beneficial to query the physician to determine patient’s visual category to be more specific with coding of low vision and blindness. Also, the laterality of the low vision and blindness is necessary in retrieving the most specific code.
Along with these changes come the need for increased specificity for diagnoses. To assign specified codes, coding specialists rely on clinicians and physicians to provide adequate detailed information about each diagnosis being listed on the plan of care. Without this important step, coding specialists are left to code only unspecified diagnoses, which could impact reimbursement, or cause a delay in coding as a query may be necessary. To reduce queries to your clinical leadership and clinicians, here are some tips on being proactive with detailed information:
  • Query the provider for specifics that are not included in the physician documentation prior to completing assessment.
  • Specify sites and laterality of wounds
  • Specify etiology of wounds (surgical, traumatic, diabetic, arterial, venous, etc)
  • Query the provider for late effects of CVA if there are none documented in clinical paperwork
  • List the type of MI the patient experienced
  • Always document patient’s smoking/tobacco use status (current or history of, and what product)
  • Don’t list diagnoses on the plan of care that are not actively being addressed or impacting the plan of care
  • If there are diagnoses listed on the plan of care that will likely impact it, but no direct interventions regarding those conditions are present, document how they will impact the POC
  • Document if patient’s substance disorders are in remission per physician documentation or query to determine this.
  • Document the specific type of heart failure a patient has been diagnosed with
  • Specify which type of diabetes a patient has been diagnosed with, and what, if any, manifestations are present.
For the coding specialists to capture more specific diagnoses based on the clinician’s documentation, clinicians should document in the clinical note that this specific information was provided by the physician. Clinicians can document specificity but unless there is verbiage stating that the condition is physician confirmed, the coding specialists cannot code that specific condition. Select Data enjoys working closely with clinicians to provide the codes being captured in the plan of care. It is truly a team- work experience. If you have any OASIS review or Coding questions please call Select Data at 1.800.332.0555.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.

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New Bundled Payment Projects

Legislation, Payment Updates


New Bundled Payment Projects: Get Prepared Now or Risk being Passed Over by the Hospitals

Agencies should prepare NOW developing Cardiac and/or Orthopedic Best Practice programs if they are not already present. Conduct statistical analysis reflecting outcomes. Demonstrate your agency’s value and strengths to that acute care hospital. If you already have a program, run the analytics. Show the value of your Agency’s specific care.


On July 25, 2016, CMS released the proposed rule stating they intend to test new bundled payments to Hospitals for the following diagnoses: Myocardial Infarcts (MIs), Coronary Artery Bypasses (CABGs), and Surgical Hip/Femur fractures. This proposal is similar to the Comprehensive Care for Joint Replacement (CJR) model that began the Spring of 2016. That proposal made hospitals responsible for the first 90 days of cost following hospital discharge for that condition. CMS has been pleased with the results thus far.

The new models would run from July, 2017- 2021 and like the CJR model, the hospital providing the procedure would be held accountable for costs and quality of care from surgery through 90 days post acute care. Of course, the hospital will be able to choose the post acute providers.

Agencies should prepare NOW developing Cardiac and/or Orthopedic Best Practice programs if they are not already present. Conduct statistical analysis reflecting outcomes. Demonstrate your agency’s value and strengths to that acute care hospital. If you already have a program, run the analytics. Show the value of your Agency’s specific care.

How to Show YOUR AGENCY’s Value

Gather emergent and rehospitalization data such as number of patients cared for and the resulting rehospitalization admission rate. Be prepared to discuss what makes your Cardiac program successful and why your agency will be an excellent partner.

CMS will choose 98 markets by random selection. Those hospitals working with post acute care providers including physicians are expected, by CMS, to deliver care that is at a “quality adjusted target price, while meeting or exceeding quality standards, and would be paid the savings achieved.”

For the Surgical Hip/Femur Fracture Treatment, that model will be placed in 67 areas where the CJR is ongoing. This looks to be an add-on to the present project. This diagnosis is the eighth most common discharge diagnosis for Medicare fee for service patients in a hospital. CMS has noted that mortality rates associated with this diagnosis is 5%- 10% after 1 month and approximately 33% at a year.


Centers for Medicare & Medicaid (2016). Bundled Payments for Care Improvement (BPCI) Initiative: General Information. Retrieved from:
For clinical record document review and coding services that can assist you with these models and more, CONTACT SELECT DATA at 1.800.332.0555

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