The Patient-Driven Groupings Model (PDGM), model focuses more heavily on clinical characteristics as expressed through coding, is a big change for home health agency payments this year. In PDGM, the principal diagnosis code reported on the home health claim assigns the period of care to a clinical group that corresponds to the principal reason the patient is receiving the services; the payment stems from the clinical group. This recent article exposed some myths that can impact home health payments.
Unspecified codes. In the coding world, unspecified codes have been considered the codes of last resort. ICD-10-CM expands coding availability to such a degree that a specific code is usually possible. However, the authors make clear that some unspecified codes – such as CHF, atrial fibrillation and COPD, unspecified – are, in fact, acceptable primary diagnoses for home health payment. Unspecified laterality, or an unspecified body site are usually not acceptable.
Symptom codes. Symptom codes are coded from the R category of ICD-10, and usually are unacceptable primary codes for home health services, which means they are non-payable because they are not assigned to a clinical group. Some examples cited by CMS include weakness, unsteadiness on feet, or fatigue, which are too vague to warrant payment of home health services. Coding rules require that when symptoms can be ‘packaged’ into a diagnosis, the diagnosis itself is coded, not the symptoms. One exception to this rule is dysphagia, which is payable even if it cannot be linked to a cause, such as stroke.
Co-morbidities. Secondary diagnoses also factor into the case-mix assignment for home health. Agencies can report up to 24 secondary diagnoses that may be eligible for payment, even if they are unacceptable as primary codes. If anyone says otherwise, he is perpetuating the last myth mentioned in the article.
As always, complete, accurate and specific diagnoses conveyed by the clinician help agencies support medical necessity and justify the use of home health resources.