The Patient-Driven Groupings Model (PDGM), implemented by CMS on January 1, 2020, brought significant changes to home health care, particularly in how OASIS assessments are coded. Previously, home health agencies were limited to recording only six diagnosis codes on the OASIS. Now, under PDGM, this has expanded significantly, allowing for up to twenty-five diagnoses to be included in the OASIS assessment.
This expansion in the number of allowable diagnoses was intentionally designed to empower Home Health Agencies (HHAs) to more comprehensively report patient conditions. By including co-morbidities and risk factors, HHAs can better articulate the complexity of patient care needs, justify the necessity for a broader range of services, and ultimately, ensure appropriate reimbursement. It’s crucial to remember that the selection of diagnoses must always be substantiated by documentation from physician face-to-face encounters, hospital discharge summaries, or physician’s office records. This ensures the accuracy and validity of the coded information within the OASIS assessment.
Do’s of Home Care Coding under PDGM
1. Align OASIS ICDs with Referral Documentation from the Physician
Medicare mandates that a licensed physician must authorize all home health care services. Consequently, HHAs are required to obtain documented evidence of this physician’s order for home health care. This order can be provided in various forms, such as a Discharge Summary, Referral document, Patient Assessment, History and Physical report, or a Physician Progress Report. While these documents serve as the basis for the physician’s order, they may not always explicitly list the ICD-10-CM diagnosis codes that should be used on the OASIS assessment.
In cases where the physician’s documentation doesn’t include specific ICD-10-CM codes, it becomes the HHA’s responsibility to select the most appropriate code from the ICD-10-CM code list that accurately reflects the documented diagnosis. Conversely, if the referral documentation does provide specific diagnosis codes, these are the codes that should be utilized when completing the OASIS assessment.
How to Select the Primary Diagnosis
The principal reason for requiring home care, as denoted by OASIS item M1021, invariably serves as the primary diagnosis. The physician who formally approves the plan of care (CMS485), known as the ‘certifying’ physician, is responsible for determining and documenting the primary diagnosis during the mandatory face-to-face encounter with the patient. It is the certifying physician’s assessment that dictates the primary diagnosis for home health coding purposes.
Understanding the Physician Face-To-Face Encounter
The ‘physician face-to-face’ encounter is a critical Medicare requirement for initiating home health services, but it’s important to note that it is not required for recertification. Medicare stipulates that within the period of 90 days prior to the start of care date, or within 30 days following it, the certifying physician must provide documentation detailing how the patient’s clinical condition, observed during this specific face-to-face encounter, justifies the patient’s homebound status and the need for skilled services.
This ‘face-to-face’ encounter documentation may or may not be included within the written referral documentation previously mentioned. Crucially, a suitable ICD-10-CM diagnosis code may or may not be explicitly stated in the narrative of the face-to-face documentation. If a diagnosis code is not included in the narrative, the HHA is obligated to select the ICD-10-CM code that most accurately represents the problem described in the physician’s narrative. However, if the physician does include a specific ICD-10 code, then this code should be used for OASIS item M1021. It’s important to reiterate that face-to-face encounter documentation is only a prerequisite for the initial certification of home health services.
2. The Primary Diagnosis Must Have a PDGM Classification
Addressing Situations Where the Primary Diagnosis Lacks PDGM Classification
In the event that the initially identified primary diagnosis does not have a corresponding PDGM classification, the HHA is required to consult with the certifying physician. This consultation is necessary to collaboratively identify a suitable alternative diagnosis that not only accurately reflects the patient’s condition but also meets the PDGM classification requirement for primary diagnoses in home health.
Don’ts of Home Care Coding under PDGM
Don’t Code ICDs That Cannot Be Supported by Physician’s Referral Documentation
To ensure compliance and prepare for potential Medicare audits of patient charts, it is imperative that all diagnoses coded in the OASIS assessment are fully verifiable by the physician or hospital referral documentation. Coding diagnoses without proper documentation can lead to discrepancies and potential issues during audits. Maintaining a clear and auditable trail of documentation is a cornerstone of compliant home care coding practices under PDGM.
