Sixty percent of the top 10 primary home health diagnoses in the first five months of 2020 consist of conditions exclusively grouped to either cardiac or respiratory categories. This grouping may indicate that coders are responding to PDGM’s specificity requirements.
The data, which looks at a total of 545,182 periods from Strategic Healthcare Programs National Client Database, shows the true diagnoses underlining the need for home care.
The top primary codes are:
- I11.0 (Hypertensive heart disease with heart failure): 14%
- I13.0 (Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease): 12%
- I10 (Essential (primary) hypertension): 11%
- I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris): 10%
- J44.9 (Chronic obstructive pulmonary disease, unspecified): 9%
- J44.1 (Chronic obstructive pulmonary disease with (acute) exacerbation): 8%
Use these codes correctly as they drive payments in PDGM, and auditors will look at them closely. All these codes except I10 (Essential (primary) hypertension) drive high comorbidity adjustments in addition to being codes that drive payment as primary.
Cardiopulmonary conditions make up a major portion of chronic health conditions cared for by home care providers. It is rare to code a patient in the elderly population that does not have a diagnosis related to the heart, particularly hypertension (HTN).
Be sure to query when needed
Do not assign these diagnoses in the primary spot if their genuine focus of care is not a valid primary diagnosis, rather than querying the physician/provider for the needed detail.
Quick tips for coding cardiac and pulmonary conditions
- Always remember there is an assumed relationship between HTN and heart disease unless otherwise specified.
- Be aware of the Excludes 1 note for COPD and emphysema coding as you cannot code both J44- and J43- categories simultaneously. Emphysema is considered a more specific diagnosis and takes precedence unless the scenario includes documentation of chronic obstructive bronchitis.
- Never code symptoms inherent to the cardiopulmonary disease processes such as SOB, weakness, or peripheral edema.
- Be as specific as you can with your coding based on the medical records.