While the proposed payment rule is yet to be finalized, home health providers need to familiarize themselves with the impending coding changes and how these will affect Patient-Driven Groupings Model (PDGM) calculations. Based on the proposed payment rule, we have made a breakdown of possible coding-related changes to look out for.
Coding for Recertifications
Currently, coding for a new start of care (SOC) OASIS or recertification of a patient requires that the patient’s primary diagnosis be driven by the primary focus of care for the 60-day episode.
However, under the proposed rule and with the implementation of OASIS-E, there will not be a diagnosis to put on a recertification OASIS. Even if coding in a Recertification OASIS will no longer exist, the plan of care (POC) and orders to take care of the patient during a recertification period should still contain all diagnoses.
Updates on Comorbidity Subgroups
In the proposed rule, there are 23 subgroups for low comorbidity adjustments and 94 high comorbidity adjustments, compared to the present number of 20 and 87 subgroups respectively.
The following will be completely removed from the low comorbidity calculation:
- musculoskeletal 1 diagnoses
- respiratory 9 diagnosis
The following will be added to the secondary low comorbidity adjustment list:
- circulatory 2
- gastro 1
- neo 3
- neuro 12
- respiratory 10
The proposed rule reassigns 320 diagnosis codes to a different clinical group if they are listed as primary, and 37 diagnosis codes when listed as secondary. 159 diagnosis codes will also be completely removed from the list of acceptable primary diagnoses under PDGM, which means they cannot be used as the primary diagnoses on claims starting January 1, 2023 once software systems will be updated.
Moreover, the proposed rule reassigns diagnosis code U09.9 — post COVID–19 condition, unspecified — from comorbidity subgroup, respiratory 2 to respiratory 10.
Changes in F2F Encounter
Since 2015, agencies have been required to provide an actual encounter note from the practitioner who conducted the face-to-face encounter. The form before the 2015 revision of the face-to-face encounter instructions will no longer be acceptable, so agencies need to stop using it if they still are.
In addition, the primary diagnosis on a POC should be treated during the face-to-face encounter. For the face-to-face encounter and your patient’s home health certification to be valid and real, there has to be a treatment order, medication change, or something that the physician has documented showing that they have assessed and treated that diagnosis in the encounter note.
Starting training for the new coding practices might be too early, but advance planning and preparation for the forthcoming changes will be beneficial. With the new value-based payment approach and threatening cuts to home health payments, optimizing coding and reimbursements are crucial for home health businesses.
Make sure your coding team or provider is updated with the latest home health coding standards and is proactive in recognizing opportunities to maximize the reimbursement potential of each patient case.