OASIS Complete Webinar Series Selecting Clinically Relevant and Fiscally Appropriate Diagnoses Presented By: Rhonda Marie Will, RN, BS, HCS-D, COS-C October 1, 2010 243 King Street, Suite 246 Northampton, MA 01060 413-584-5300 fax: 413-584-0220 e-mail: info@fazzi.com www.fazzi.com
Instructions and Handouts for: Selecting Clinically Relevant and Fiscally Appropriate Diagnoses 11 12 10 9 8 7 6 1 2 3 4 5 Eastern Standard Time 1:00 PM to 2:00 PM 11 12 10 9 8 7 6 1 2 3 4 5 Central Standard Time 12:00 PM to 1:00 PM 11 12 10 9 8 7 6 1 2 3 4 5 Mountain Standard Time 11:00 AM to 12:00 PM 11 12 10 9 8 7 6 1 2 3 4 5 Pacific Standard Time 10:00 AM to 11:00 AM It is very important that you have these materials printed and ready to use prior to the start of the training. In order to participate in this training you will need to do the following: Dial 1-877-615-4339 at least 10 minutes prior to the start of the webinar. 1. When asked, enter Conference ID 6013828#. 2. Give your agency s name. 3. At this time you will be entered into the call and in listen mode. 4. If at any time you need assistance you may press *0 for the operator. 5. There will be a Q & A period toward the end of the session. Questions will be answered in the order in which they are received. To ask a question, press *1. You will have the opportunity to ask your question and then be returned to listen mode. Do not press *1 prior to this time. 6. To view the presentation online you must click on the link sent to you from GoToWebinar. Nurses Only: Directions to complete the webinar evaluation. 1. We appreciate your feedback. Please complete our post-webinar survey after the session has ended. Note: This educational activity does not contain contact hours. Click on the following link in order to access the online evaluation form: https://www.surveymonkey.com/s/gf2hzfr *Please allow four weeks for processing.
Speaker Information Rhonda Will, RN, BS, COS-C, HCS-D is the Assistant Director of the OASIS Competency Institute for Fazzi Associates, Inc. As a registered nurse she has worked in home health care since 1979 in various clinical, administrative and management roles. Rhonda has extensive experience in staff and program development and as a consultant and trainer. Her areas of expertise include OASIS assessment and diagnosis selection and ICD-9-CM skill building, documentation, care planning and management, and regulatory compliance. With Fazzi Associates Rhonda has developed OASIS and clinical training programs, record audits for reimbursement and quality and ICD-9-CM Coding training. She presents educational programs on site and by audio/video conferencing for home health agencies, state and national home health associations and industry vendor sponsored meetings.. Rhonda provided clinical leadership for the 2003 3M National OASIS Integrity Project and the 2009 National Best Practices OASIS C Project with Fazzi Associates. Recognized as an industry expert, she gave feedback on data items in the CMS draft OASIS C Guidance Manual and The Handbook of Home Health Standards: Quality, Documentation and Reimbursement (5th ed.) by Tina Marelli. Rhonda served on the Editorial Board for Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional from 2008-2010 and conducts peer review for draft magazine articles. Fazzi Associates, Inc. 2
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OASIS-Complete Webinar Series Selecting Clinically Relevant and Fiscally Appropriate Diagnoses October 1, 2010 Rhonda Will, RN, BS, COS-C, HCS-D Assistant Director of OASIS Competency Institute Fazzi Associates, Inc. rwill@fazzi.com Objectives Define the criteria for primary and secondary diagnoses Discuss the contribution of diagnoses to risk adjustment of patient outcomes Diagnosis Directions OASIS C Guidance Manual M1020/1022/1024 Appendix D ICD-9 CM Official Guidelines for Coding and Reporting Current ICD-9-CM code book Medicare Claims Processing Manual Chapter 10 Sec. 40.2 Fazzi Associates, Inc. 4
Diagnosis Statements Support the Plan of Care/485 Communicate description of the patient Support MCR eligibility ibilit and coverage criteria i Contribute to Reimbursement Supply risk factors for Quality Patient Outcomes Provide information for data analysis 51 variables PPS Scoring Variables 30 relate to diagnosis M1020/M1022/M1024 Primary, secondary or both (17) Interaction of 2 diagnoses (2) Interaction with other OASIS items (11) 15 additional clinical OASIS items 6 functional OASIS items Table 4: 5 of 51 Case Mix Adjustment Variables Line # Episode 1 or 2 (Early) 1 or 2 3+ (Late) 3+ Therapy visits 0-13 14+ 0-13 14+ 5 Other Diagnosis = Diabetes 2 4 1 4 11 Primary or Other Diagnosis = Heart Disease or Hypertension 3 7 1 8 Primary or Other Diagnosis = Ortho1-Leg Disorder or Gait Disorders 19 AND 2 0 0 0 M1324 (most prob PU stage) = 1, 2, 3 or 4 33 M1200 (Vision) = 1 or more 1 0 0 1 48 M1840 (Toileting) = 2 or more 2 3 2 0 Fazzi Associates, Inc. 5
Case Mix Diagnosis Groups January 2008 Blindness and Low Vision GI Disorders Blood Disorders Heart Disease Cancer and Select Benign Neoplasms Diabetes Dysphagia Gait Abnormality Hypertension Neuro 1 - Brain Disorders and Paralysis Neuro 2 - Peripheral Neurological Disorders Neuro 3 - Stroke Case Mix Diagnosis Groups January 2008 Neuro 4 Multiple Sclerosis Pulmonary disorders Ortho 1 Leg disorders Skin 1 Traumatic wounds, burns and post operative complications Oth Ortho 2 Other Orthopedic Skin 2 Ulcers and other skin disorders conditions Psych 1 Affective and other psychoses, depression Psych 2 Degenerative and other organic psychiatric disorders Tracheostomy care V55.0 Urostomy/Cystostomy Care V55.5 and V55.6 OASIS regulation Responsibilities Clinical assessor responsible for: Comprehensive assessment Identification of diagnoses Symptom control ratings May consult with office based staff for diagnosis selection and coding guidance Fazzi Associates, Inc. 6
Office staff may: Assign ICD9 code Responsibilities Discuss sequencing requirements with clinical assessor Alert clinical assessor when POC or assessment does not support dx selection Make changes ONLY with an addendum preserving the original document, after conferring with clinical assessor and documenting agreement with the changes Rhonda s Rules Be able to defend your diagnosis selections Don t set the visiting staff up to fail Discuss the diagnoses with the clinician in the context of the POC What do you plan to do? What can I expect you will document over the next 60 days? Best Practice! Complete diagnostic statements and assign codes AFTER the comprehensive assessment is complete--when you understand the patient s specific health status. Fazzi Associates, Inc. 7
M0230 Primary Diagnosis Diagnosis most related to the current Plan of Care Chief reason for providing home care considering all disciplines May be represented by the most intensive skilled services May or may not be related to a patient s recent hospital stay M1022 Secondary Diagnosis All conditions that coexist at the time the POC is established Conditions which affect the treatment or care of the patient Should include not only conditions actively addressed in POC but also any comorbidity affecting the patient s responsiveness to treatment and rehabilitation prognosis, even if the condition is not the focus of any home health treatment itself Fazzi Associates, Inc. 8
M1022 Secondary Diagnosis Conditions which develop subsequent to the established POC (for recertification) Avoid listing diagnoses of mere historical interest or without impact on patient progress or outcome V Codes - Over Used! Supplemental codes used to describe reason for encounter with home care provider; reason for aftercare Sequence at the bottom of the list unless Appropriate as the PDX One of the three codes on the case mix list V55.0 tracheostomy V55.5 cystostomy V55.6 other artificial opening of urinary tract, nephrostomy, ureterostomy, urethrostomy List diagnoses: Sequencing In accordance with the MCR Claims Processing Manual and OASIS instructions To best reflect the seriousness of the patient s condition To justify disciplines and services provided In accordance with the Official ICD-9-CM Guidelines for Coding and Reporting Etiology and manifestation with mandatory sequencing Code first, code also Coding order of other secondary dx is discretionary With consideration of case mix adjustment Clinical points are additive, not duplicative Fazzi Associates, Inc. 9
Symptom Control Rating Rate the degree of symptom control for the condition listed in Column 1 excluding V and E codes 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 M1024 Payment Diagnosis (Optional) Appendix D - Complete Column 3: When M1020 PDX or M1022 SDX is a V code AND V code displaces a case mix code AND Case mix code is inappropriate in M1022 SDX (e.g. acute fracture code) To prevent loss of case mix points when M1020 PDX is a V code AND V code displaces a case mix code AND Case mix code is from HH PPS Diagnosis Group (Table 3) Diabetes Skin 1 (traumatic wounds, burns, post op complications) or Neuro 1 (brain disorders and paralysis) Appendix D General criteria for M1024: V code reported in M1020/1022 is replacing a case mix diagnosis that is not appropriate to report as underlying or associated diagnosis in M1022 No surgical codes Code underlying diagnosis to M1020/1022 only if surgery did not eliminate the disease No E codes Code relevant medical diagnosis No V codes Fazzi Associates, Inc. 10
M1024 Payment Diagnosis (Optional) Complete Column 4 when the code book says to do so! Etiology and manifestation codes Mandatory multiple coding Appendix D Avoid assigning excessive number of V codes Limit the number of diagnoses in M1024 Prevent Coding for Payment from occurring Report fraudulent coding to the administrator of the HHA. If no action, report to RHHI hotline or State Surveyor hotline Appendix D Comply with ICD-9-CM Coding Guidelines Code only those diagnoses that are unresolved Code only relevant medical diagnoses Code only diagnoses supported by the medical record documentation i.e. POC and comprehensive assessment Ensure compliance with ICD 9 CM sequencing requirements Fazzi Associates, Inc. 11
Avoid selecting: Appendix D Non-specific or ambiguous diagnosis Symptom diagnosis General symptomatic complaint in the elderly population Appendix D HHAs no longer must always code a numeric diagnosis code in M1024 if a V code assigned to M1020/M1022 replaces a case mix diagnosis code. The reason is that ICD-9-CM coding guidelines state that certain rehabilitation and aftercare V codes need a secondary diagnosis in M1022 to describe a resolving condition or sequelae. In some cases, such underlying or associated diagnoses are case mix codes representing the underlying condition displaced by the V code. M1010 Inpatient Diagnoses List conditions actively treated during an IPF stay that ended within the last 14 days; Something more than regularly scheduled meds and treatments to maintain an existing condition Time Points Fazzi Associates, Inc. 12
M1012 Inpatient Procedures Medical procedures relevant to the home health POC AND occurring during an IPF stay that ended within the last 14 days. Time Points M1016 Diagnoses Requiring Medical or Treatment change within past 14 days Due to a decline or exacerbation within the last 14 days, conditions which caused a change in: medical or treatment regimen health care services Medications NA- changes in regimen were due to an improvement in condition or no changes occurred Excludes any changes that occurred 15 or more days ago even if related to IPF stay Time Points Fazzi Associates, Inc. 243 King Street, Suite 246 Northampton, MA 01060 800-379-0361 www.fazzi.com rwill@fazzi.com Fazzi Associates, Inc. 13