Documentation Myth


When you code, what do you review?

One myth that is prevalent in home health is that the nurse must chart on the primary diagnosis.  This is a good rule of thumb but it is not a law or anything.  You will not go to jail if you venture off into another relevant area of patient care.

These are some of the errors we see because the focus of the nurses and coders is narrowed to the ‘primary diagnosis.

  1. The patient experiences an exacerbation or a new diagnosis and the clinician documents something like, ‘Pt reports falling this morning when trying to get out of bed.  Taught that concentrated sweets can raise blood sugar.”
  2. The patient is on multiple medications for hypertension but miraculously the patient does not have a diagnosis of hypertension anywhere.
  3. A poorly chosen primary diagnosis makes it to the initial plan of care and the obedient nurse documents on it throughout the episode.   When it comes time to code the second episode, the coder reads through the notes and determines that most care went to the bad diagnosis and re-codes with the same error.
  4. We continue to see low vision coded without a supporting diagnosis that cannot be corrected with lenses.
  5. Hospital paperwork mentions diseases and conditions that are nowhere to be found in the home health care chart.

So, back to the original question.  What are you reviewing?  If you are looking a the diagnoses that the nurse wrote on her assessment and simply applying the coding conventions, you need to find out where she is getting her information.  If she is repeating the same diagnoses as before, they may be wrong.  If there are no changes, the patient appears to be static to the Medicare computers that run edits on your claims placing you at high risk for scrutiny.

Coding that is compliant with all regulations doesn’t happen in one place.  The clinician must document accurately regardless of the coding sequence was at the beginning of the episode.  If necessary, complete a Significant Change in Condition Assessment.  Alternatively, if you believe that the coding was performed incorrectly, contact the person who does your coding and make clear why you think it is wrong.

Medicare expects you to code accurately but they do not expect you to be clairvoyant.  If your patient with diabetes as a secondary diagnosis has a sustained blood elevated blood sugar, it should not be ignored in the notes.

When the visit note content is a true and accurate reflection of the patient and you have all the supplemental information such as lab, hospital documents, etc., then true and correct codes may be assigned.  Coders need to learn to look for clues that the documentation isn’t as it should be. 

Initially, this may delay dropping a RAP for a day or so but it is better than leaving hundreds of dollars on the table or putting yourself at risk for denials. Good coding will eventually be the starting point of a more efficient process which will result in your agency fine tuning multiple processes improving patient care, communication and cash.  What’s wrong with that?

If you need help coding or billing, don’t hesitate to give us a call.  We can help you get your processes streamlined and improve your cash.  See the coupon below for a special offer for the first five readers who respond. 


One Comment

  1. I have been in Home Health Care for 34 years and I have never just documented towards the primary diagnosis. We take care of the whole patient and my expectations of the nursing staff woould be the same. I agree with you whole-heartedly regarding documentation as it needs to paint a picture of the patient’s total being as it all affects healing one way or another. Documentation is key to reimbursement and it always has been. If we cannot prove that we this patient

    improved in any way as a result of our care, then why should we be paid


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