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. 


Hospice Coding

coding wordle 2


72 percent of hospice claims list only one diagnosis.  The diagnosis used most often is Debility. The third most frequently used diagnosis is adult failure to thrive. 

That means that upwards of 75 percent of hospices may have some real problems soon.  The requirement that hospices adhere to the ICD-9 coding guidelines is not new.  It is written into the original 1983 hospice guidelines and CMS is very much aware that hospices are not following the long established rules of coding.

Hospices have responded by building cheat sheets and lists of common hospice diagnoses.  It’s a great idea but it probably won’t work.  It didn’t work for hospitals in the 90’s or home health agencies after their prospective payment system was refined in 2008.  To this day agencies that depend on untrained nurses to code are losing money by insufficient coding or worse, getting denied because of invalid codes.

The biggest mistake that home health agencies made all those years ago after PPS was implemented was not taking coding seriously.  With four exceptions, the ICD-9 coding performed by an agency did not affect payment.  As such, diagnosis coding was not taken very seriously by home health. 

That turned out to be a mistake. Diagnoses that required significant resources to treat were not included in future updates to the payment system.  Incorrect, poorly specified diagnoses were included but when coded correctly, they did not add to the reimbursement.

I am not going to pretend that I am psychic and charge you for my insight into the future.  I can only say that I see this happening to the Hospice Industry in the not-so-distant future.

How could this stubborn insistence on following the rules be any worse, you ask?  It comes right as the rest of the world is transitioning into ICD-10 coding.  That’s right.  By the time you get the hang of ICD-9 Coding, the rules of the game will change.

It’s almost as though Medicare has taken up our cause as their own and has begun emphasizing the value of our coding services.  Thank you, Medicare for the plug.  Can we talk about the face-to-face requirement, now?

If you do not want to outsource coding, there are other options (but none as good as contracting with us or another reputable company).

  1. If your hospice has common ownership with a home health agency, remember that this is not new to them.  Make some kind of arrangement with them. 
  2. When you are recruiting nurses or billers, put coding on the top of the list of preferred skills.
  3. Go online and look for certified coders.  Remember, coders do not have to be nurses.
  4. If there is a school that offers RHIT certification in your area, offer a student internship.  You might end up with the employee of a lifetime or a dud.  It is worth the gamble because they are trained in coding, electronic health information, etc.   
  5. Outsource ICD-9 coding and focus on investing in ICD-10 coding preparation for your staff. 

Remember, people do not wake up one morning and try as hard as they can to thrive and fail.  If you cannot come up with a good underlying reason, expect denials.  Not being paid fairly could easily be the result of poor coding which might lead to a poor outcome for hospices that go the extra mile to ensure patients and their families are comfortable at the end of life.  It takes resources to provide the kind of care that matters.  Don’t cheat your hospice or your patients by failing to take this seriously.

As always, Delaine and Jackie can be reached via email or you can call 337-654-7934. 

There’s More to Coding than Billing

Having spent the last 20 or so years in home health, I have absolutely no use whatsoever for an ICD-9 code other than billing.  As I nurse I don’t treat 401.9 or 250.02.  I treat people with hypertension or diabetes.  The only time a code is important to me is when it comes time or billing.  At that point, the code better be correct and accurately describe the patient.  In fact, my standard response to the oh so popular question, ‘Which code pays the most?’ is, ‘The code that most accurately describes your patient.’

So every once in a while some academic association or research group reminds me that ICD-9 and soon to be ICD-10 codes are used for tons of reasons.  Epidemiological studies and clinical research are often driven by coding.  I imagine that’s how they make those seasonal flu maps.  It’s probably easier than going state to state and taking a headcount.  The prevention and detection of healthcare fraud and abuse is one that some providers don’t take very seriously but many claims are chosen because of a diagnosis and some other factor.  It certainly doesn’t mean that you shouldn’t use the code because the best code is….. the one that most accurately describes the patient.  And the whims of CMS change.

As the government gets more involved in health care whether you think it’s a good idea or not, icd-9 codes will be pivotal to setting health policy.

In reading some of the studies presented to congress over the past several years that ultimately resulted in changes to our payment system, it occurred to me that if we had answered the OASIS questions correctly and coded the diagnoses properly, the changes would not have been as devastating.  It is hard to imagine that your codes will make a difference in the payment system five years down the line but if everyone thinks that way, the payment system will continue to reflect decisions made on poor data.

So make sure that all OASIS responses and codes are chosen with care.  If you have questions, you can ask them here and we will get back to you.  If your agency uses professional coders, make sure that  you give them the information they need to code.  We can help you with that, too.




The E Codes


Perhaps this fall into the category of useless information but you never know.  What if you have to code a patient who was being abused by her husband right when a terrorist’s bomb exploded causing the windows to break and cut her.  What if the same person got into her car and drove as fast as she could to get out of there and ended up getting in a dreadful motor vehicle accident. Wouldn’t it be dreadful if while she was unconscious from the auto accident, the flood waters started rising and nearly drowned her.   How on earth would you sort those E codes out?

  1. E codes for child and adult abuse take priority over all other E codes.
  2. E codes for terrorism events take priority over all other E codes except child and adult abuse.
  3. E codes for cataclysmic events take priority over all other E codes except child and adult abuse and terrorism.
  4. E codes for transport accidents take priority over all other E codes except cataclysmic events, child and adult abuse and terrorism.

It gets even more complicated if a transportation accident involves more than one type of vehicle.  Spacecraft always comes first followed by watercraft, motor vehicles, trains and other.

Thankfully, the likelihood that you would have to code all of these at one time is pretty slim.  So all you really need to remember is that when using multiple E codes, abuse trumps all and transport accidents are right behind abuse.

Nobody is going to lose any money if you don’t use E codes properly.  You probably will stay off the federal investigator’s watch list if you neglect an E code now and them.  So why should you use them?  The answer is simple.  If your coding paints as complete of a picture as possible of a patient, less attention will be paid to the visit notes.  In Medical Review, only eligibility and reasonable and necessary are scrutinized.  If a reviewer sees a trauma code followed by an E code for an MVA, the reasonable and necessary requirement is very firmly supported.

Plus some of the E-codes are just fun.

  • E906.3  (What is an aparthod?)
  • E014.1  (A real threat to home health workers)
  • E029.2 (Happens everyday)
  • E875.0  (Wash your Hands!!)
  • E908.8 (Common code last week in some parts)

Don’t forget that you can click on the ‘Ask the Coders’ button on the top bar any time you have a question.