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Coding Reminders and Red Flags

    Accurate and patient-specific coding is crucial to succeeding with the Patient-Driven Groupings Model (PDGM). Proper diagnosis coding ensures you receive the appropriate payment while addressing your patients’ healthcare needs.

    Submitting claims with coding errors can lead to the claim being returned to the agency for code adjustments, which can have long-term consequences. Regulators will likely closely scrutinize agencies that consistently submit invalid codes as the primary diagnosis.

    The following are key factors to keep in mind in coding, as well as coding issues that may raise concerns for auditors:


    • Physician verification and documentation of diagnoses are necessary.
    • Consistency of diagnoses is required across all documentation in the patient’s chart – the claim, the Plan of Care (POC)/CMS 485, and the OASIS.
    • All coding must comply with the official ICD-10-CM coding guidelines.
    • Symptoms part of a disease process/condition should not be coded unless instructed to do so by the coding guidelines. 
    • Do not list resolved diagnoses.
    • Diagnoses must be accurate and clearly explain why the patient needs home care.
    • Diagnosis sequencing should reflect the seriousness of each condition and support the provided skilled services.
    • The primary diagnosis is defined as the “chief reason the patient is receiving home care” and the most related to the current home care POC.
    • Secondary diagnoses should impact the skilled services provided and be addressed in the POC.
    • Each ICD-10 code should be entered at its highest level of specificity.
    • Avoid the use of “unspecified” codes and consult with the physician for more specific codes when documentation is insufficient.

    Red Flags:

    • Using the same top six case-mix diagnoses for multiple patients on different claims is a red flag – Each patient’s condition should be evaluated and documented individually, based on the specific severity of their disease processes.
    • Listing all diagnoses with an exacerbation and/or onset date as the admission or recertification date on the POC – These dates should be specific to each diagnosis and not generalized to one specific date such as the admission or recertification date. While listing these dates is no longer mandatory, if the agency chooses to include them, they must be accurate.
    • Coding diagnoses that are not present in the patient’s billing history, except for home care-specific codes like aftercare codes or attention codes – Physician-originated diagnoses supported by documentation can help avoid this issue from occurring.
    • Using acute codes that are not appropriate for home care claims
    • Coding manifestation codes as primary diagnosis.
    • Coding superficial wounds inappropriately – Clear documentation should support the wound code used on the claim, OASIS, and POC.
    • Documentation that contradicts the type of wound/ulcer being treated – Seek physician clarification if documentation regarding ulcer type is unclear.
    • Coding cancer diagnoses incorrectly as acute (active) versus being part of the patient’s medical history – Always verify that the physician’s documentation supports the current active treatment and/or not eradication of cancer and does not merely indicate the patient’s medical history.
    • Coding diagnoses that are not supported in the POC, medication profile, and/or referral documentation

    Importance of Best Practices in PDGM Coding and Documentation

    Agencies may have a basic understanding of PDGM coding a year after its rollout. However, knowing and applying best practices can significantly improve reimbursement values and avoid setbacks from audits or claim denials. It is important that coders can analyze each patient case and work proactively with other functions, such as intake, billing, and QA, to ensure that documentation is complete and consistent in supporting the relevant diagnosis codes for the patient’s case.