icd-10 icd-10c oding for homeh ealth -...

Joan L. Usher, BS, RHIA, COS-C, ACEAHIMA-approved ICD-10-CM Trainer

ICD-10 Codingfor Home HealthA Guide to Medical Necessity and Payment

Ush

erIC

D-10 C

oding for Hom

e Health


ICD-10 Codingfor Home Health

A Guide to Medical Necessity and Payment

Have you started your ICD-10 training? If you haven’t, the time to start is right now! Nationally recognized coding expert Joan L. Usher, BS, RHIA, COS-C, ACE, an AHIMA-approved ICD-10-CM trainer, will help you begin with her new, comprehensive ICD-10 coding training manual. Specific to home health, this book gives detailed coding training and how-to guidance for the top diag-noses in the homecare setting and breaks down some of the biggest changes in ICD-10.

Beginning in October 2014, home health agencies must include ICD-10 coding on their claims to prove medical necessity of their services per Medicare coverage guidelines. ICD-10 coding is com-plex, and even the most seasoned ICD-9 coder will need education and training to code correctly under ICD-10 due to the significant increase in codes and required specificity.

ICD-10 Coding for Home Health: A Guide to Medical Necessity and Payment provides coding tutorials, as well as analysis and guidance on the most common diagnoses and most challenging coding situations within homecare. The book also features an exam to test your knowledge and ensure coder proficiency.

This book includes:• Coding how-to for the most common diagnoses in homecare• Overview of OASIS-C1 and how it will accommodate ICD-10 codes• Guidance on how to properly document and code in ICD-10 to ensure proper Medicare payment

ICD10CHH

75 Sylvan Street | Suite A-101 | Danvers, MA 01923www.beaconhealth.org

ICD10CHH_Cover2014.indd 1 1/29/14 3:53 PM

Joan L. Usher, BS, RHIA, COS-C, ACE, AHIMA Approved ICD-10-CM Trainer


ICD-10 Coding for Home Health: A Guide to Medical Necessity and Payment

ii

© 2014 Beacon Health, a division of HCPro

ICD-10 Coding for Home Health: A Guide to Medical Necessity and Payment is published by

Beacon Health, a division of HCPro.

Copyright © 2014 Beacon Health, a division of HCPro.

All rights reserved. Printed in the United States of America. 5 4 3 2 1

ISBN: 978-1-61569-279-8

No part of this publication may be reproduced, in any form or by any means, without prior written

consent of HCPro, a division of BLR, or the Copyright Clearance Center (978/750-8400). Please notify

us immediately if you have received an unauthorized copy.

HCPro provides information resources for the healthcare industry.

HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint

Commission trademarks.

Joan L. Usher, Author

Casey Pickering, Editor

Adrienne Trivers, Product Manager

Vicki McMahan, Sr. Graphic Designer

Michael McCalip, Graphic Design/Layout

Matt Sharpe, Production Coordinator

Shane Katz, Cover Design

Advice given is general. Readers should consult professional counsel for specific legal, ethical, or

clinical questions.

Arrangements can be made for quantity discounts. For more information, contact:

Beacon Health, a division of HCPro

75 Sylvan Street, Suite A-101

Danvers, MA 01923

Telephone: 800/553-2041

Fax: 800/639-8511

Email: [email protected]

Visit Beacon Health online at:

www.beaconhealth.org


iii


Contents

About the Author..................................................................................v

Acronym Guide....................................................................................vii

PART I: Understanding the Fundamentals of ICD-10-CM Coding

1. Introduction ................................................................................................................................. 3

2. The Origins of ICD Coding ........................................................................................................... 7

3. Getting to Know the ICD-10 Manual ......................................................................................... 15

4. Understanding the Coding Manual—Format & Setup ................................................................ 21

5. Conventions and Terms .............................................................................................................. 39

6. Four Easy Steps to Accurate Coding ........................................................................................... 49

PART II Home Health Specifics—What You Need to Know

7. Primary and Other Diagnoses ..................................................................................................... 55

8. Effective Management of the Coding Process ............................................................................ 67

9. Coverage Criteria ....................................................................................................................... 77

10. OASIS ........................................................................................................................................ 87

11. Receiving Appropriate Reimbursement ....................................................................................... 99

12. Case-mix and Coding .............................................................................................................. 111

13. Ethical Coding Practice ............................................................................................................ 117


iv


Part III: “How-to” Chapters on Each Diagnostic Area

14. Certain Infectious and Parasitic Diseases (A00–B99) ................................................................. 125

15. Neoplasms (C00–D49) ............................................................................................................. 137

16. Diseases of the Blood and Blood-Forming Organs and Certain Disorders

Involving the Immune Mechanism (D50–D89) .......................................................................... 147

17. Endocrine, Nutritional, and Metabolic Diseases (E00–E89) ........................................................ 151

18. Mental, Behavioral, and Neurodevelopment Disorders (F01–F99) ............................................. 159

19. Diseases of the Nervous System and Sense Organs (G00–G99) ................................................ 167

20. Diseases of Eye and Adnexa (H00–H59) ................................................................................... 177

21. Diseases of Ear and Mastoid Process (H60–H95) ...................................................................... 183

22. Diseases of the Circulatory System (I00–I99) ............................................................................ 187

23. Diseases of the Respiratory System (J00–J99) ........................................................................... 199

24. Diseases of the Digestive System (K00–K95) ............................................................................ 207

25. Diseases of the Skin and Subcutaneous Tissue (L00–L99) ......................................................... 215

26. Diseases of the Musculoskeletal System and Connective Tissue (M00–M99) ............................ 225

27. Diseases of the Genitourinary System (N00–N99) ..................................................................... 235

28. Pregnancy, Childbirth, and the Puerperium (O00–O9A) ............................................................ 241

29. Conditions Originating in the Perinatal Period (P00–P96) ......................................................... 247

30. Congenital Anomalies (Q00–Q99) ............................................................................................ 253

31. Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not

Elsewhere Classified (R00–R99) ................................................................................................ 257

32. Injury and Poisoning and Certain Other Consequences of External Causes (S00–T88) .............. 267

33. External Causes of Morbidity (V01–Y99) .................................................................................. 283

34. Factors Influencing Health Status and Contact with Health Services (Z00–Z99) ........................ 291

35. Final Exam ............................................................................................................................... 301

Book Resources..................................................................................315


v


About the Author

Joan L. Usher, BS, RHIA, COS-C, ACE

Joan L. Usher, BS, RHIA, COS-C, ACE, president of JLU Health Record Systems in Pembroke, MA

(www.jluhealth.com), is a nationally recognized expert in the field of ICD-10-CM coding and health

information management. She has a degree in Health Information Management and is a registered

health information administrator. Her career began at a Visiting Nurse Association, and she has

been consulting for more than 25 years. She is also a certified Outcome and Assessment Informa-

tion Set (OASIS) specialist in the clinical realm.

Usher is a past president of the Massachusetts Health Information Management Association (Ma-

HIMA), a component state organization of the American Health Information Management Associa-

tion (AHIMA). Under her leadership, Massachusetts received four national awards from AHIMA in

continuing education programs, support for accredited HIM education, legislative advocacy, and

electronic communications. She was the recipient of the 2008 Professional Achievement Award

from MaHIMA. Usher is a regular lecturer in Massachusetts, Connecticut, Rhode Island, and

New Hampshire. She is also on the board of directors for the Home Care Alliance (HCA) of MA

and Hospice and Palliative Care Federation of Massachusetts. She is the cochair of the ICD-10

Committee of MaHIMA and facilitator of the ICD-10 Group for the HCA of MA.

Usher has taught ICD-9 coding in home health for more than 15 years and has educated more than

10,000 people nationwide. She has authored several publications, including the Rapid Reference

Coding Guide, which provides homecare organizations with an easy format to look up the most

frequently used ICD-9-CM and ICD-10-CM codes in home healthcare, ICD-10 Essentials for Home-

care, Beacon Health 2011, ICD-9 Coding for Home Health: A Guide to Medical Necessity & Payment,

Beacon Health 2010, and ICD-9 Coding for Home Health: A Comprehensive Guide, HCPro 2008.

Usher is the author/editor of three online e-learning coding courses for AHIMA: Home Health

Diagnostic Coding, Home Health Reimbursement Methods, and Home Health Documentation &

Health Record Requirements, 2011. In partnership with Libman Education, she has authored an


vi


online course, ICD-10 Coding for Post Acute Care, 2013. She was also a contributing author to

Schraffenberger & Kuhn, Effective Management of Coding Services, AHIMA, 2010.

Usher’s other accomplishments include multiple presentations and webinars on the release of

information, electronic health records, Healthcare Insurance Portability and Accountability Act,

performance improvement and data quality, and hospice coding. She had been a contributing

author and editor for the Massachusetts Medicolegal Guide (MaHIMA). Usher currently writes

a monthly coding column for Homecare Direction, Beacon Health’s monthly homecare newsletter.


vii


Guide to Common Acronyms

485 Home Health Certification &

Plan of Care (Form CMS 485)

AHIMA American Health Information

Management Association

AHA American Hospital Association

BBA Balanced Budget Act of 1997

(PL 105-33)

CDC Centers for Disease Control

and Prevention

CMS Centers for Medicare &

Medicaid Services

COPs Conditions of Participation

(Medicare)

DME Durable Medical Equipment

FI Fiscal Intermediary

FY Fiscal Year

HAVEN Home Assessment

Validation Entry

Acronym Guide

HIPPS Health Insurance Prospective

Payment System

HHA Home Health Agency

HHRG Home Health Resource Group

HIPAA Health Insurance Portability

and Accountability Act of 1996

ICD-9-CM International Classification

of Diseases

LUPA Low Utilization Payment

Adjustment

NCHS National Center for

Health Statistics

NQF National Quality Forum

OASIS Outcome and Assessment

Information Set

OBQI Outcome-Based Quality

Improvement

OBQM Outcome-Based Quality

Management


viii


OIG Office of the Inspector General

PEP Partial Episode Payment

PPS Prospective Payment System

PT Physical Therapist

RHHI Regional Home Health

Intermediary

SLP Speech-Language Pathologist

QIO Quality Improvement

Organizations

UB-04 Uniform Bill 04

CHAPTER 1

Introduction

ICD-10 Coding for Home Health: A Guide to Medical Necessity and Payment© 2014 Beacon Health, a division of HCPro

Proper ICD-10-CM coding is essential for accurate case-mix management and reimbursement.

ICD-10-CM coding is based on a classification system that assigns an alphanumeric code, which

describes a patient’s various diseases, injuries, and procedures.

The World Health Organization (WHO) issues ICD codes and the Centers for Medicare & Medicaid

Services (CMS) publishes updates on a biannual basis. Home health regulations require listing the

primary diagnosis and other pertinent diagnoses and codes on both the Outcome and Assessment

Information Set (OASIS) and the Home Health Certification and Plan of Care (commonly known as

Form CMS-485).

The purpose of this guide is to assist home health agency (HHA) staff in understanding the basics

of the ICD-10-CM and the specifics of home health coding. The goal is to provide an introduction

and overview of the common diagnoses used in the home health industry today to provide the

framework for planning and preparing for the transition to ICD-10-CM. ICD-10 Coding for Home

Health: A Guide to Medical Necessity and Payment is divided into three parts:

• Part 1: Understanding the Fundamentals of ICD-10-CM Coding. This section of the book

encompasses Chapters 1–6 and addresses the basics of ICD-10 coding, provides a historical

perspective on coding, and takes the reader through the critical steps in learning how to code.

• Part 2: Home Health Specifics: What You Need to Know. This part, which includes Chapters

7–13, teaches the specifics of coding correctly in an HHA and the documentation required for

correct coding and reimbursement.

• Part 3: How-to Chapters for Each Diagnostic Area. The final sections, Chapters 14–34, build

on your knowledge and address each body system. Each how-to chapter contains exercises to

test your knowledge of the subject.

The main benefits to correct coding are appropriate reimbursement for services rendered and

compliance with local, state, and federal guidelines. A secondary benefit to learning the correct

CHAPTER

1 Introduction


Chapter 14


way to code includes accurate data collection for research and outcomes management. Reimburse-

ment from the Medicare benefit is paid under a prospective payment model. Payment categories,

called Home Health Resource Groups, use the OASIS document as the data collection tool. One

miscoded record can cause an average revenue loss to an agency of $360 to $1,200.

Understanding the fundamentals of accurate coding with ICD-10-CM will allow your HHA to

receive appropriate reimbursement and for decreased turnaround time for claims.



Ush

erIC

D-10 C

oding for Hom

e Health


ICD-10 Codingfor Home Health

A Guide to Medical Necessity and Payment

Have you started your ICD-10 training? If you haven’t, the time to start is right now! Nationally recognized coding expert Joan L. Usher, BS, RHIA, COS-C, ACE, an AHIMA-approved ICD-10-CM trainer, will help you begin with her new, comprehensive ICD-10 coding training manual. Specific to home health, this book gives detailed coding training and how-to guidance for the top diag-noses in the homecare setting and breaks down some of the biggest changes in ICD-10.

Beginning in October 2014, home health agencies must include ICD-10 coding on their claims to prove medical necessity of their services per Medicare coverage guidelines. ICD-10 coding is com-plex, and even the most seasoned ICD-9 coder will need education and training to code correctly under ICD-10 due to the significant increase in codes and required specificity.

ICD-10 Coding for Home Health: A Guide to Medical Necessity and Payment provides coding tutorials, as well as analysis and guidance on the most common diagnoses and most challenging coding situations within homecare. The book also features an exam to test your knowledge and ensure coder proficiency.

This book includes:• Coding how-to for the most common diagnoses in homecare• Overview of OASIS-C1 and how it will accommodate ICD-10 codes• Guidance on how to properly document and code in ICD-10 to ensure proper Medicare payment

ICD10CHH

75 Sylvan Street | Suite A-101 | Danvers, MA 01923www.beaconhealth.org

ICD10CHH_Cover2014.indd 1 1/29/14 3:53 PM

icd-10 icd-10c oding for homeh ealth -...

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