The introduction of the Patient Driven Groupings Model (PDGM) by CMS on January 1, 2020, brought significant changes to home health care, including how home health OASIS assessments are coded. Previously, only six diagnosis codes were recorded; now, home health agencies (HHAs) can include up to twenty-five diagnoses on the OASIS assessment.
This expansion aims to provide a more comprehensive picture of the patient’s condition by allowing HHAs to report co-morbidities and risk factors. This detailed reporting reflects the complexity of patient care, the potential need for extensive services, and consequently, appropriate reimbursement. Crucially, the diagnoses selected for the OASIS assessment must be substantiated by physician documentation, such as face-to-face encounter notes, hospital discharge summaries, or physician office records.
Do’s of Coding Under PDGM
1. Align OASIS ICD Codes with Physician Referral Documentation
Medicare mandates that a licensed physician must authorize home health care services. The HHA is responsible for obtaining documented evidence of this physician’s order. Acceptable forms of documentation can include: Discharge Summaries, Referrals, Patient Assessments, History and Physical reports, and Physician Progress reports. These documents may or may not explicitly list the ICD-10-CM diagnosis codes that will be used on the OASIS assessment.
If the physician’s documentation does not include specific ICD-10-CM codes, the home health coder must select the most appropriate code from the official ICD-10-CM code list. Conversely, if the referral documentation does provide diagnosis codes, these should be utilized for the OASIS assessment.
How to Select the Primary Diagnosis
The primary diagnosis, which corresponds to OASIS item M1021 (the main reason for home care), is always the principal diagnosis. The physician certifying the plan of care (CMS 485 form) is responsible for determining and documenting the primary diagnosis during the mandatory face-to-face encounter with the patient. This certifying physician is distinct from the referring physician.
Understanding the Physician Face-To-Face Encounter
The physician face-to-face encounter is a Medicare requirement for initiating home health services, but it is not necessary for recertification.
Medicare stipulates that within 90 days before the start of care date, or within 30 days after, the certifying physician must provide documentation detailing how the patient’s clinical condition, as observed during the face-to-face encounter, justifies the patient’s homebound status and the necessity for skilled services. This face-to-face encounter documentation may or may not be part of the initial written referral.
A suitable ICD-10-CM diagnosis code may or may not be included within the narrative of the face-to-face documentation. If a diagnosis code is absent from the narrative, the HHA coder is required to select the code that most accurately reflects the problem description provided. If the physician does include a diagnosis code, that code will be used for M1021. It’s important to remember that face-to-face encounter documentation is only mandatory for the initial certification period. [Alt text: PDGM Diagnosis Coding Guide Download Button: Click to download a comprehensive guide on PDGM diagnosis coding for home health agencies.]
2. Ensure the Primary Diagnosis Has a PDGM Classification
According to Home Health Care Coding Guidelines, the primary diagnosis must fall into one of the twelve PDGM clinical groupings. Out of over 70,000 ICD-10-CM diagnosis codes, approximately 43,000 are classified under PDGM and are eligible for use as a primary diagnosis. A comprehensive list of ICD-10-CM diagnosis codes with PDGM classifications is available on the CMS website. Click here to access the list of ICD-10-CM Diagnosis codes that have a PDGM classification.
What if the Primary Diagnosis Lacks PDGM Classification?
In situations where the initially identified primary diagnosis does not have a PDGM classification, the HHA must consult with the patient’s physician to determine a suitable alternative diagnosis that meets this essential requirement for PDGM compliance.
Don’ts of Coding Under PDGM
Don’t Code ICDs Without Physician Referral Documentation Support
To protect against potential Medicare audits of patient charts, it is crucial to ensure that every diagnosis coded is verifiable through the physician or hospital referral documentation. Coding diagnoses that lack this supporting documentation can lead to claim denials and compliance issues.
PDGM Home Health Billing: Significant Change in Condition (SCIC)
