Under the Patient-Driven Groupings Model (PDGM), the “best” acceptable primary code is key to agency reimbursement. And while practicing according coding ethics, some coders feel pressured to simply choose an “acceptable” code when documentation does not support one.
“Acceptable” is not always acceptable
Some coders report that when their intake department accepts a referral with an unacceptable primary diagnosis, they are asked to find some acceptable billable diagnosis as primary that will “work” even if not the primary reason for home care per the referral and clinician’s start-of-care notes. This is a common practice that home health coding experts say they have seen since the start of PDGM.
Therapy codes, such as abnormality of gait and frequent falls, continue to be the cause of many of these instances. CMS states it is up to the physician to determine the underlying cause of a fall or weakness.
Keep in mind that most Medicare Advantage plans require a PDGM HIPPS code when billing. For instance, an agency obtained authorization for several visits by providing M62.81, Muscle weakness, and Z86.73, Personal history of TIA and cerebral infarction without residual deficits, to the payer. Neither of these codes, however, is an acceptable primary diagnosis for PDGM and failure to use an acceptable diagnosis will result in failure to generate a HIPPS code for billing.
Knowing that this HMO will not allow the claim to bill without a valid PDGM HIPPS and that these codes will not generate one, the coder sent the chart back asking for a valid diagnosis. The agency argued they were fine since they got visit authorization, not understanding that authorization for visits is not a guarantee of payment and that the payer may still have additional billing requirements that must be met in addition to obtaining authorization. When the payer, Medicare traditional or Medicare Advantage, requires a PDGM HIPPS code, it must be supplied on the claim or non-payment will result, regardless of pre-authorization received.
Scrutinize documentation
Implementing a compliant query process under PDGM is important and experts say there is an increase in queries to providers for more clear documentation. Agencies must follow compliant query practice and track provider response.
Intake could determine if the primary diagnosis is a PDGM acceptable diagnosis. But some coders say that despite how much they educate their referral sources it just doesn’t seem to be getting through and some are considering having the coders review the referral information instead.
If it’s not possible for your coders to review the referral information, then great communication and ongoing education between intake and coding is of the utmost importance. Educate the physician before a referral is sent in, but especially when it is recognized as an unacceptable diagnosis.
Fix it now, or wait later
The biggest risk you face is denials. If the face-to-face documentation does not have a qualifying diagnosis that matches the plan of care, your agency is at risk of that claim being denied due to inadequate face-to-face documentation.
This will also cause payment delays as you can’t bill for the episode until eligibility is assured by obtaining an acceptable PDGM primary diagnosis. Most agencies continue to see patients during the period they are trying to obtain an acceptable diagnosis, so episode costs continue to be incurred, while the ability to bill for the episode remains unknown.
If you’re in a state with Review Choice Demonstration (RCD), this causes even bigger issues because you can’t submit the pre-claim review submission until coding is completed, and the plan of care is signed and returned.
A delay in obtaining an acceptable diagnosis of 10 to 15 days into a billing period can result in billing delays by multiple billing periods, since you need to obtain the signed plan of care, submit to pre-claim review and then wait up to 10 days for a response. This also may require additional information and re-submission before provisional affirmation for billing can be made.
Aside from billing, there is also a question of compliance if you continue to see the patient without an acceptable PDGM primary diagnosis.
While other patient diagnoses may be known, the primary diagnosis should represent the focus of care. It calls into question what skill and the quality of that skill being provided when you don’t know the patient’s actual diagnosis upon which care should be based.
Here’s a perfect example
A patient comes to home care with a large open hematoma and wound vac, and needs wound care three times a week.
The initial thought is to code the hematoma as primary. However, the wound care is the skilled need, and the wound care is the primary need for home health.
Therefore, code Z48.00 should be primary and the episode groups to wound. It just requires a little more thought in many cases.