ICD-10 Guidance Impacts 2015 Home Health Grouper
August 21, 2015 08:29 AM
The National Association for Home Care & Hospice (NAHC) has recently learned that the organizations responsible for the official International Classification for Disease (ICD)-10 coding guidance has issued clarification that would require home health agencies to indicate an “A” (initial encounter) in the 7th character for some ICD-10 codes. An “A” in the 7th character should be used for any encounter where the patient is still receiving active treatment for the clinical condition, including home health. While in many cases this would not apply to home health, there are times where it could, such as antibiotic treatment for a postop infection.
Until now both home health coding experts and CMS have understood that an “A”- initial encounter” would never be appropriate as the 7th character for a home health diagnosis since the patient would have always been seen initially in another setting. However, the definition of initial encounter in the ICD-10 coding guidelines is broader than many realized.
In the ICD-10-CM Official Guidelines for Coding and Reporting, the following language is used to help coders determine when an “A” should be used in the 7th character:
“While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.”
“For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem. For example, code T84.50XA, Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter, is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device, implant or graft that was placed at a previous encounter.”
The main concern for home health providers with this new guidance is that the 2015 Grouper, effective for claims spanning October 1– December 31 2015, does not allow for case mix and non-routine supply (NRS) points for any ICD-10 code with an “A” in the 7th character.
The potential magnitude of the problem could be larger than what CMS anticipates. Claims with a diagnosis for wound dehiscence, post-op infection of surgical wound, or non-healing of a surgical wound could be impacted.
NAHC is currently waiting for confirmation from CMS as to how this issue will be addressed. It appears that claims will need to be adjusted since it is unlikely that the Grouper can be updated so close to the ICD-10 implementation date.