ICD-9-CM Home Health Coding Impact on Reimbursement

Transcription

1 ICD-9-CM Home Health Coding Impact on Reimbursement Presented by HealthCare ConsultLink Linda Parker, RN, BSN, COS-C, HCS-D Objectives Identify principles for determining primary/secondary diagnoses Identify when to complete M1024 List 3 possible negative impacts of coding on reimbursement Source Documents CMS OASIS-C Guidance Manual Chapter 3 pages C-8 through C-11 ICD-9-CM Official Guidelines for Coding and Reporting Home Health Prospective Payment System regulations 1

2 DETERMINING PRIMARY DIAGNOSIS: The logic for determining the primary (first listed) diagnosis remains unchanged. CMS definition The principal diagnosis is the diagnosis most related to the current plan of treatment. It may or may not be related to the patient s most recent hospital stay, but must relate to the services the home health agency rendered. If more than one diagnosis is treated concurrently, enter the diagnosis that represents the most acute condition and requires the most intensive services. Skilled services (SN, PT, OT and SP) only. DETERMINING PRIMARY DIAGNOSIS: The assessing clinician has to determine the primary and secondary diagnoses and symptom control rating, after completing the OASIS Assessment Why am I seeing this patient? What is the primary focus of skilled services? Are there co-morbidities that may impact the POC? Do not consider the number of visits per discipline as a basis for your decision! Determining Primary/Secondary Diagnoses: INCLUDE those conditions actively addressed as well as any co-morbidities affecting the patient s response to treatment EXCLUDE diagnoses that no longer pertain to the plan of care, i.e., hip fracture, appendicitis, gangrene, etc. 2

3 Co-Morbidity Information: There are some co-morbidities that should always be coded because they are impacted or they may impact the care. CMS states that any co-morbidity affecting the patient s responsiveness to treatment and rehabilitative prognosis, even if the condition is not the focus of any home health treatment itself, should be listed. ALWAYS CODE THESE CO-MORBIDITIES Diabetes HTN COPD CHF CAD Status Sausamputation pua PVD Blindness Chronic diseases, such as Parkinson s History of malignant neoplasm when care is directed at a current neoplasm or otherwise impacts the care Co-Morbidity Information Plan of Care should reflect all diagnoses including co-morbidities #21 SN to assess diabetes and HTN for potential impact on plan of care #22 Patient will have no complications related to diabetes and HTN this episode If therapy only, co-morbidities must also be addressed in therapy Plan of Care PT to check blood pressure every visit and report to physician if >185/95 and/or < 90/60 Patient s blood pressure will remain within parameters this episode 3

4 Primary/Secondary Diagnoses DO NOT automatically code something without physician documentation ti or communication with the physician documented, i.e., urinary retention or neurogenic bladder Guidance from Official Coding Guidelines A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient s diagnosis. Guidance from Medicare CoP (a) Standard: Plan of Care If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modification to the original plan. 4

5 Guidance from OASIS Manual Agencies should avoid listing diagnoses that are of mere historical interest and without impact on the patient progress or outcome. (OASIS-C Guidance Manual Chapter 3 Item Intent C-9) Coding Impact on Reimbursement Payment based on an HHRG (Home Health Resource Group) OASIS items M0110 and M2200 determine payment equation 20 additional OASIS items determine Clinical severity score Functional severity score Service Utilization severity score ICD-9-CM codes are part of the clinical severity score Coding Impact on Reimbursement Clinical Domain 22 Diagnostic Categories 1 - Blindness & Low Vision 12 - Neuro 3 (Stroke) 2 - Blood Disorders 13 - Neuro 4 (MS) 3 - Cancers & Neoplasms 14 - Ortho 1 (Leg) 4 - Diabetes 15 - Ortho 2 (Other) 5 - Dysphagia 16 - Psych 1 (Affective) 6 - Gait Abnormality 17 - Psych 2 (Degenerative) 7 - Gastrointestinal Disorder 18 - Pulmonary 8 - Heart Disease 19 - Skin 1 (Trauma & Burns) 9 - Hypertension 20 - Skin 2 (Ulcers & Other) 10 - Neuro 1 (Brain) 21 - Tracheostomy Care 11 - Neuro 2 (Peripheral) 22 - Urostomy/Cystostomy Care 5

6 Coding Impact on Reimbursement See Handout # 1 Table 5 Case-Mix Adjustment Variables and Scores Coding Impact on Reimbursement Potential points for M1020a and M1022b-f Potential points for combined diagnoses See Variable 6 Potential points for combination with M00 item See Variable 7 Out of 22 diagnostic categories only 3 with potential for UPCODING Diabetes Diagnostic Group 4 Neuro 1 Diagnostic Group 10 Skin 1 Diagnostic Group 19 6

7 Coding Impact on NRS See Handout # 2 Table 6 Non-Routine Supply Case-Mix Adjustment Variables and Scores Other ICD-9-CM Coding impacts on reimbursement - Codes must match on the OASIS, POC (485), and the bill (UB04) OASIS M1020 and M1022 has 6 spaces for codes POC (485) has unlimited spaces UB04 Claim form has 9 spaces + E Code Other ICD-9-CM Coding impacts on reimbursement - Not following rules for sequencing manifestations Leaving off a required 4 th or 5 th digit of the code Not completing M1024 7

8 Completing M1024 See Handout # 3 OASIS-C M1020, M1022, M1024 (M1020) Primary Diagnosis & (M1022) Other Diagnosis (M1024) Payment Diagnoses (OPTIONAL) Column 1 Column 2 Column 3 Column 4 Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided) ICD-9-C M and symptom control rating for each condition. Note that the sequencing of these ratings may not match the sequencing of the diagnoses Description ICD-9-C M / Symptom Control Rating (M1020) Primary (V-codes are allowed) Diagnosis a. ( - ) a Complete if a V-code is assigned under certain circumstances to Column 2 in place of a case mix diagnosis. Description/ ICD-9-C M (V- or E-codes NOT allowed) a. ( - ) Complete only if the V- code in Column 2 is reported in place of a case mix diagnosis that is a multiple coding situation (e.g., a manifestation code). Description/ ICD-9-C M (V- or E-codes NOT allowed) a. ( - ) (M1022) Other Diagnoses b. (V- or E-codes are allowed) b. ( - ) (V- or E-codes NOT allowed) b. ( - ) (V- or E-codes NOT allowed) b. ( - ) Completing M1024 M1024 is a Case Mix MONEY item Per CMS, M1024 is optional you don t have to claim payment Grouper programmed to go to M1024 if a V code is in M1020 or M1022 8

9 M1024 facts M1024 does not automatically go to the UB04 or 485 as it for HHRG calculation only Diagnosis must be in M1020 or M1022 to appear on 485 or UB04 Guidance from CMS the diagnosis in M1024 must appear on the 485 either in items 11, 13 or 21 So must ASK M1024 facts Does the condition still exist? If no, then list in M1024 and include on 485 #21 but DO NOT list in M1022 If yes, then no need to list in M1024 per Attachment D guidelines as will be in M1022 as condition still exists When to complete M1024 Skip M1024 if No V code in Column 2 for M1020 or M1022 V code in Column 2 M1020 or M1022 and DOES NOT replace a Case Mix Diagnosis 9

10 When to complete M1024 Complete M1024 if V code in M1020 or M1022 and it replaces a Case Mix Diagnosis That is not resolved or Gives more points Diabetes, Skin 1 or Neuro 1 Aftercare following right hip joint replacement due to traumatic fracture. SN for PT/INR, Stage 1 pressure ulcer left hip and PT for gait abnormality. M1020 Primary & M1022 Other Diagnoses M1024Case Mix Diagnoses (OPTIONAL) (1) (2) (3) (4) a. After following joint replacement a. V54.81 a. Fx hip 820 b. Pressure ulcer left hip b b. b. c. Stage 1 pressure ulcer c c. c. d. Joint, hip d. V43.64 d. d. e. Encounter for therapeutic e. V58.83 e. e. drug monitoring f. Anticoagulant f. V58.61 a. Aftercare following BKA due to gangrene in a diabetic patient with PVD. SN for dressing change, diabetic teaching and PT for gait abnormality. M1020 Primary & M1022 Other Diagnoses M1024Case Mix Diagnoses (OPTIONAL) (1) (2) (3) (4) a. Other aftercare following specified surgery a. V58.49 a. Diabetes b. Diabetes with peripheral b b. b. manifest c. PVD c c. c. d. Lower limb amputation d. V49.75 d. d. status e. Dressing change e. V58.31 e. e. f. f. f. f. a. Gangrene

11 PT to eval and treat arthropathy of the lower leg due to Reiter s Disease. M1020 Primary & M1022 Other Diagnoses M1024 Case Mix Diagnoses (OPTIONAL) (1) (2) (3) (4) a. PT a. V57.1 a. a. b. Reiter s Disease b b. b. c. Arthropathy c c. c. d. d. d. d. e. e. e. e. f. f. f. f. Specific Diagnostic Category Considerations Diabetes 250 Category (Variables 4 & 5) CODING DIABETES 250.xx requires both a 4 th and 5 th digit 4 th digit = without or with complication 5 th digit = type and if controlled or not Usually requires 2 codes 11

12 Coding Diabetes Subcategory (4 th digit) Requiring a Manifestation Code 250.4x with renal manifestation 250.5x with opthalmic manifestation 250.6x with neurological manifestation 250.7x with peripheral circulatory disorders 250.8x with other specified manifestations 250.9x unspecified complication DO NOT USE Diabetic Coding Tips: Diabetes/macular edema requires 3 codes: 250.5x x Diabetes/acute osteomyelitis requires 3 codes: 250.8x x Diabetic Coding Tips: Use V58.67 with Type 2 diabetics on insulin to paint better picture Do not use V58.67 with Type I diabetics as redundant 12

13 A patient is admitted to home care with uncontrolled, Type 2 diabetes. The insulin regime has been modified and the patient is to be monitored for overall condition. Patient also has diagnosis of diabetic polyneuropathy. M1020 Primary & M1022 Other Diagnoses M1024 Case Mix Diagnoses (OPTIONAL) (1) (2) (3) (4) a. Diabetes, type 2 with neuro manifestation a a. a. b. Polyneuropathy b b. b. Would Agency get the primary Diabetes points? A patient is admitted to home care with uncontrolled, Type 2 diabetes. The insulin regime has been modified and the patient is to be monitored for overall condition. Patient also has diagnosis of diabetic polyneuropathy. M1020 Primary & M1022 Other Diagnoses M1024 Case Mix Diagnoses (OPTIONAL) (1) (2) (3) (4) a. Diabetes, type 2 with neuro manifestation a a. a. b. b. b. b. Would Agency get the primary Diabetes points? Specific Diagnostic Category Considerations Blindness These codes are used to show type of visual impairment due to a condition, e.g., glaucoma, cataracts, etc. Not used for refractive errors 369.x codes are NOT used just because they are old that would be UPCODING! Legal Blindness in the United States is coded differently from WHO definition - choose your codes carefully 13

14 Specific Diagnostic Category Considerations Neuro 3 Stroke, to include: Hemiplegia and Hemiparesis Monoplegia Cauda Equina Syndrome Late Effects CVA Neuro Neglect Syndrome (Variables 10, 15, 16, 17) Specific Diagnostic Category Considerations - CVA Late effects of CVA may require Only a 4 th digit A 5 th digit 4 th digit and an additional code 5 th digit and an additional code Muscle weakness, seizures or contractures as late effect of CVA are coded with Patient referred to home care following an acute CVA with flaccid hemiplegia affecting dominant side and dysphagia requiring enteral feeding (M1030 Therapy in home = 3). SN, PT, OT and ST ordered. OASIS-C scores dressing lower body as 2 and ambulation as 4. M1020 Primary & M1022 Other Diagnoses M1024 Case Mix Diagnoses (Optional) a. Late effects of CVA w/hemiplegia b. Late effects of CVA w/dysphagia c. Dysphagia, unspecified (1) (2) (3) (4) a a. a. b b. b. c c. c. How many Clinical points if Early episode and 20 therapy visits? 14

15 MS patient requires monthly foley catheter change by SN. No recent exacerbations of MS. Physician has verified urinary incontinence as reason for catheterization. M1020 Primary & M1022 Other Diagnoses M1024 Case Mix Diagnoses (Optional) (1) (2) (3) (4) a. Fitting and adjustment a. V53.6 a. a. of urinary catheter b. Ui Urinary incontinence b b. b. c. MS c. 340 c. c. Would Agency get the MS points? How many NRS points? Specific Diagnostic Category Considerations Ortho Note that many Ortho 1 and Ortho 2 codes are Manifestation Codes and must be partnered with the underlying cause to qualify for points Specific Diagnostic Category Considerations V Codes V55.0 Tracheostomy Care (Variable 29) V55.5 Cystostomy Care V55.6 Other artificial Opening of Urinary Tract Nephrostomy, Ureterostomy, Urethrostomy (Variable 30) 15

16 SCENARIOS Scenario 1 REFERRAL INFORMATION: Left hip fracture and Stage 1 pressure ulcer on coccyx Physical therapy 3 times a week for gait and balance training DATA OBTAINED THROUGH ASSESSMENT: Minoxidil found in home Amputation of third and fourth toes, right foot 10 years ago due to trauma injury List diagnoses that you can code at this point: List diagnoses that physician must confirm: 16

17 What is the primary reason for home care in M1020? Sequence other diagnoses for home care that would go in M1022: Any codes in M1024? Scenario 2 REFERRAL INFORMATION: Fall at home resulting in 2 skin tears (category 3) to right forearm and one skin tear (category 2) to right elbow. Daily dressing change. Uncontrolled type 1 diabetes. Muscle weakness requiring physical therapy. DATA OBTAINED THROUGH ASSESSMENT: Patient states legally blind and has tingling in feet Lexapro found in home and patient exhibiting S/S depression List diagnoses that you can code at this point: List diagnoses that physician must confirm: 17

18 What is the primary reason for home care in M1020? Sequence other diagnoses for home care that would go in M1022: Any codes in M1024? Scenario 3 REFERRAL INFORMATION: Hypertensive heart disease; uncontrolled blood pressure; Atrial fib and on Coumadin SN to monitor BP daily for 2 weeks; obtain PT/INR on admit and weekly for 2 weeks CABG 6 months ago following MI DATA OBTAINED THROUGH ASSESSMENT: Patient states physician told him he had heart failure New RX Nexium found in home and patient c/o heart burn List diagnoses that you can code at this point: List diagnoses that physician must confirm: 18

19 What is the primary reason for home care in M1020? Sequence other diagnoses for home care that would go in M1022: Any codes in M1024? Scenario 4 REFERRAL INFORMATION: Primary focus of care is aftercare following surgery for malignant melanoma of skin on upper arm. Cancer completely removed and no further treatment ordered. Dressing change ordered. DATA OBTAINED THROUGH ASSESSMENT: Patient unable to administer Vit B12 injections due to surgery and no available caregiver List diagnoses that you can code at this point: List diagnoses that physician must confirm: 19

20 What is the primary reason for home care in M1020? Sequence other diagnoses for home care that would go in M1022: Any codes in M1024? Scenario 5 REFERRAL INFORMATION: Acute exacerbation of COPD with asthma requiring oxygen Muscle weakness due to CVA 8 months ago requiring PT History of HTN DATA OBTAINED THROUGH ASSESSMENT: Oxygen delivered yesterday and patient concerned about use Refuses PT until dyspnea improves List diagnoses that you can code at this point: List diagnoses that physician must confirm: 20

21 DETERMINE TOTAL POINTS per Equation M1020 Primary & M1022 Other Diagnoses Points per Equations Diagnosis Code (1) (2) (3) (4) Chr obstr asthma If Ambulation = 1 or more Late effect CVA If Drsg upper or lower body = 1, 2, or 3 If Ambulation = 3 or more Muscle weakness HTN Oxygen V46.2 TOTAL Possible Points IN SUMMARY Negative impacts of coding on reimbursement.. M1024 not completed when a V code replaces a case mix diagnosis in M1020 or M1022 Diagnosis does not include all required digits Required manifestation code not listed 21

22 Negative impacts of coding on reimbursement.. Manifestation code sequenced above etiology Not all co-morbidities are listed, i.e. blindness, hypertension, CHF, COPD, history of neoplasm Negative impacts of coding on reimbursement.. Not all diagnoses are listed, i.e., pressure ulcer (stage 1), depression Sequencing of diagnoses not supported by documentation UPCODING Diabetes, Skin 1 & Neuro 1 Categories To Rise to the Challenge and Thrive.. Utilize current ICD-9-CM Coding Manuals Be aware of annual changes to codes Ensure staff receive basic coding and OASIS education on hire and at least annually 22

23 To Rise to the Challenge and Thrive.. DO NOT give in to Panic attack Excessive crying of the adult Insomnia, unspecified Gastric ulcer Adult emotional/psychological abuse 23

24 Table 5 (formerly Table 2A) Episode number within sequence of adjacent episodes 1 or 2 1 or CLINICAL DIMENSION Therapy visits EQUATION: Primary or Other Diagnosis = Blindness/Low Vision Primary or Other Diagnosis = Blood disorders Primary or Other Diagnosis = Cancer, selected benign neoplasms 4 Primary Diagnosis = Diabetes Other Diagnosis = Diabetes Primary or Other Diagnosis = Dysphagia AND Primary or Other Diagnosis = Neuro 3 - Stroke Primary or Other Diagnosis = Dysphagia AND M0250 (Therapy at home) = 3 (Enteral) 6 8 Primary or Other Diagnosis = Gastrointestinal disorders Primary or Other Diagnosis = Gastrointestinal disorders 3 AND M0550 (ostomy)= 1 or 2 10 Primary or Other Diagnosis = Gastrointestinal disorders AND Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis, OR Neuro 2 - Peripheral neurological disorders, OR Neuro 3 - Stroke, OR Neuro 4 - Multiple Sclerosis 2 11 Primary or Other Diagnosis = Heart Disease OR Hypertension Primary Diagnosis = Neuro 1 - Brain disorders and paralysis Primary or Other Diagnosis = Neuro 1 - Brain disorders and 3 10 paralysis 14 AND M0680 (Toileting) = 2 or more Primary or Other Diagnosis = Neuro 1 - Brain disorders and 2 4 paralysis OR Neuro 2 - Peripheral neurological disorders AND M0650 or M0660 (Dressing upper or lower body)= 1, 2, or Primary or Other Diagnosis = Neuro 3 - Stroke 1 16 Primary or Other Diagnosis = Neuro 3 - Stroke 1 AND M0650 or M0660 (Dressing upper or lower body)= 1, 2, or 3 ICD-9-CM Coding and Reimbursement Hand Out #

25 Table 5 (formerly Table 2A) Episode number within sequence of adjacent episodes 1 or 2 1 or Therapy visits EQUATION: Primary or Other Diagnosis = Neuro 3 - Stroke AND M0700 (Ambulation) = 3 or more Primary or Other Diagnosis = Neuro 4 - Multiple Sclerosis AND AT LEAST ONE OF THE FOLLOWING: 19 M0670 (bathing) = 2 or more OR M0680 (Toileting) = 2 or more OR M0690 (Transferring) = 2 or more OR M0700 (Ambulation) = 3 or more Primary or Other Diagnosis = Ortho 1 - Leg Disorders or Gait 2 Disorders 20 AND M0460 (most problematic pressure ulcer stage)= 1, 2, 3 or 4 Primary or Other Diagnosis = Ortho 1 - Leg OR Ortho 2 - Other 5 5 orthopedic disorders AND M0250 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral) 21 Primary or Other Diagnosis = Psych 1 Affective and other psychoses, depression 22 Primary or Other Diagnosis = Psych 2 - Degenerative and other organic psychiatric disorders 23 Primary or Other Diagnosis = Pulmonary disorders Primary or Other Diagnosis = Pulmonary disorders 1 AND M0700 (Ambulation) = 1 or more 25 Primary Diagnosis = Skin 1 -Traumatic wounds, burns, and postoperative complications 26 Other Diagnosis = Skin 1 - Traumatic wounds, burns, postoperative complications 27 Primary or Other Diagnosis = Skin 1 -Traumatic wounds, burns, 2 2 and post-operative complications OR Skin 2 Ulcers and other skin conditions AND M0250 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral) 28 Primary or Other Diagnosis = Skin 2 - Ulcers and other skin conditions 29 Primary or Other Diagnosis = Tracheostomy Primary or Other Diagnosis = Urostomy/Cystostomy ICD-9-CM Coding and Reimbursement Hand Out # 1

26 Table 5 (formerly Table 2A) Episode number within sequence of adjacent episodes 1 or 2 1 or Therapy visits EQUATION: M0250 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral) M0250 (Therapy at home) = 3 (Enteral) M0390 (Vision) = 1 or more M0420 (Pain)= 2 or M0450 = Two or more pressure ulcers at stage 3 or M0460 (Most problematic pressure ulcer stage)= 1 or M0460 (Most problematic pressure ulcer stage)= 3 or M0476 (Stasis ulcer status)= M0476 (Stasis ulcer status)= M0488 (Surgical wound status)= M0488 (Surgical wound status)= M0490 (Dyspnea) = 2, 3, or M0540 (Bowel Incontinence) = 2 to M0550 (Ostomy)= 1 or M0800 (Injectable Drug Use) = 0, 1, or FUNCTIONAL DIMENSION 46 M0650 or M0660 (Dressing upper or lower body)= 1, 2, or M0670 (Bathing) = 2 or more M0680 (Toileting) = 2 or more M0690 (Transferring) = 2 or more 2 50 M0700 (Ambulation) = 1 or M0700 (Ambulation) = 3 or more Notes: The data for the regression equations come from a 20 percent random sample of episodes from CY The sample excludes LUPA episodes, outlier episodes, and episodes with SCIC or PEP adjustments. Points are additive, however points may not be given for the same line item in the table more than once. Please see Medicare Home Health Diagnosis Coding guidance at for definitions of primary and secondary diagnoses. ICD-9-CM Coding and Reimbursement Hand Out # 1

27 NRS Case-Mix Adjustment Variables and Scores Item Description Score SELECTED SKIN CONDITIONS: 1 Primary diagnosis = Anal fissure, fistula and abscess 15 2 Other diagnosis = Anal fissure, fistula and abscess 13 3 Primary diagnosis = Cellulitis and abscess 14 4 Other diagnosis = Cellulitis and abscess 8 5 Primary diagnosis = Diabetic ulcers 20 6 Primary diagnosis = Gangrene 11 7 Other diagnosis = Gangrene 8 8 Primary diagnosis = Malignant neoplasms of skin 15 9 Other diagnosis = Malignant neoplasms of skin 4 10 Primary or Other diagnosis = Non-pressure and non-stasis ulcers Primary diagnosis = Other infections of skin and subcutaneous tissue Other diagnosis = Other infections of skin and subcutaneous tissue 7 13 Primary diagnosis = Post-operative Complications Other diagnosis = Post-operative Complications Primary diagnosis = Traumatic Wounds and Burns Other diagnosis = Traumatic Wounds and Burns 8 17 Primary or other diagnosis = V code, Cystostomy care Primary or other diagnosis = V code, Tracheostomy care Primary or other diagnosis = V code, Urostomy care OASIS M1322 = 1 or 2 pressure ulcers, stage OASIS M1322 = 3+ pressure ulcers, stage OASIS M1308 = 1 pressure ulcer, stage OASIS M1308 = 2 pressure ulcers, stage OASIS M1308 = 3 pressure ulcers, stage OASIS M1308 = 4+ pressure ulcers, stage OASIS M1308 = 1 pressure ulcer, stage OASIS M1308 = 2 pressure ulcers, stage OASIS M1308 = 3 pressure ulcers, stage OASIS M1308 = 4+ pressure ulcers, stage OASIS M1308 = 1 pressure ulcer, stage OASIS M1308 = 2 pressure ulcers, stage OASIS M1308 = 3+ pressure ulcers, stage OASIS M1308 Unstageable Dressing/Device OR Unstageable Slough/Eschar = OASIS M1332 = 2 (2 stasis ulcers) 6 35 OASIS M1332 = 3 (3 stasis ulcers) OASIS M1332 = 4 (4+ stasis ulcers) OASIS M1330 = 1 or 3 (unobservable stasis ulcers) 9 38 OASIS M1334 = 1 (status of most problematic stasis ulcer: fully granulating) 6 39 OASIS M1334 = 2 (status of most problematic stasis ulcer: early/partial granulation) OASIS M1334 = 3 (status of most problematic stasis ulcer: not healing) OASIS M1342 = 2 (status of most problematic surgical wound: early/partial granulation) 4 42 OASIS M1342 = 3 (status of most problematic surgical wound: not healing) 14 OTHER CLINICAL FACTORS: 43 OASIS M1630=1(ostomy not related to inpt stay/no regimen change) OASIS M1630 =2 (ostomy related to inpt stay/regimen change) Any `Selected Skin Conditions` (rows 1-42 above) AND M1630=1(ostomy not related to inpt stay/no Any `Selected Skin Conditions` (rows 1-42 above) AND M1630=2(ostomy related to inpt stay/ regimen OASIS M1030 (Therapy at home) =1 (IV/Infusion) 5 48 OASIS M1610 = 2 (patient requires urinary catheter) 9 49 OASIS M1620 = 4 or 5 (bowel incontinence, daily or >daily) 10 ICD-9-CM Coding and Reimbursement Hand Out # 2

28 (M1020/1022/1024) Diagnoses, Symptom Control, and Payment Diagnoses: List each diagnosis for which the patient is receiving home care (Column 1) and enter its ICD-9-C M code at the level of highest specificity (no surgical/procedure codes) (Column 2). Diagnoses are listed in the order that best reflect the seriousness of each condition and support the disciplines and services provided. Rate the degree of symptom control for each condition (Column 2). Choose one value that represents the degree of symptom control appropriate for each diagnosis: V-codes (for M1020 or M1022) or E-codes (for M1022 only) may be used. ICD-9-C M sequencing requirements must be followed if multiple coding is indicated for any diagnoses. If a V-code is reported in place of a case mix diagnosis, then optional item M1024 Payment Diagnoses (Columns 3 and 4) may be completed. A case mix diagnosis is a diagnosis that determines the Medicare P P S case mix group. Do not assign symptom ratings for V- or E- codes. Code each row according to the following directions for each column: Column 1: Enter the description of the diagnosis. Column 2: Enter the ICD-9-C M code for the diagnosis described in Column 1; Rate the degree of symptom control for the condition listed in Column 1 using the following scale: 0 - Asymptomatic, no treatment needed at this time 1 - Symptoms well controlled with current therapy 2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring 3 - Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring 4 - Symptoms poorly controlled; history of re-hospitalizations Note that in Column 2 the rating for symptom control of each diagnosis should not be used to determine the sequencing of the diagnoses listed in Column 1. These are separate items and sequencing may not coincide. Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided. Column 3: (OPTIONAL) If a V-code is assigned to any row in Column 2, in place of a case mix diagnosis, it may be necessary to complete optional item M1024 Payment Diagnoses (Columns 3 and 4). See OASIS-C Guidance Manual. Column 4: (OPTIONAL) If a V-code in Column 2 is reported in place of a case mix diagnosis that requires multiple diagnosis codes under ICD-9-C M coding guidelines, enter the diagnosis descriptions and the ICD-9-C M codes in the same row in Columns 3 and 4. For example, if the case mix diagnosis is a manifestation code, record the description and ICD-9-C M code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row. (M1020) Primary Diagnosis & (M1022) Other Diagnosis (M1024) Payment Diagnoses (OPTIONAL) Column 1 Column 2 Column 3 Column 4 Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided) ICD-9-C M and symptom control rating for each condition. Note that the sequencing of these ratings may not match the sequencing of the diagnoses Complete if a V-code is assigned under certain circumstances to Column 2 in place of a case mix diagnosis. Complete only if the V-code in Column 2 is reported in place of a case mix diagnosis that is a multiple coding situation (e.g., a manifestation code). Description ICD-9-C M / Symptom Control Rating Description/ ICD-9-C M Description/ ICD-9-C M (M1020) Primary Diagnosis a. (V-codes are allowed) a. ( - ) (V- or E-codes NOT allowed) a. ( - ) (V- E-codes NOT allowed) a. ( - ) (M1022) Other Diagnoses b. (V- or E-codes are allowed) b. ( - ) (V- or E-codes NOT allowed) b. ( - ) (V- E-codes NOT allowed) b. ( - ) c. c. ( - ) c. ( - ) c. ( - ) d. d. ( - ) d. ( - ) d. ( - ) e. e. ( - ) e. ( - ) e. ( - ) f. f. ( - ) f. ( - ) f. ( - ) ICD-9-CM Coding and Reimbursement Hand Out # 3