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Resource Home Health Coding

Coding for Home Heath can be tricky. There are rules to follow. Selecting a Primary DX is key.

Coding under PDGM​

1. Align OASIS ICDs with Referral Documentation from the Physician​

Medicare regulations require that a physician, with a current and active physician license, must order home health care services. The HHA must obtain written documentation of the physician’s home health care order. The order can be documented by the physician in several ways: Discharge Summary, Referral, Patient Assessment, History and Physical, Physician Progress report. The written summary may or may not actually contain the diagnoses codes you will use on the OASIS assessment. If the document does not have the actual ICD-10-CM code, you must select the most appropriate code from the ICD-10-CM list. If the report has the actual diagnosis codes, you’ll use those codes.

How to Select the Primary Diagnosis

The primary reason for home care, i.e. OASIS item M1021, is always the primary diagnosis. The physician who signs the plan of care (CMS485), i.e. the ‘certifying’ physician (as opposed to the ‘referring’ physician’) always determines the primary diagnosis and documents this during the face-to-face encounter required by Medicare.

The primary diagnosis must have a Patient-Driven Groupings Model (PDGM) classification.​

The primary diagnosis must have one of twelve PDGM classifications according to home health care coding guidelines. Of the more than 70,000 ICD-10-CM diagnosis Codes, about 43,000 have PDGM classifications and can be used as a primary diagnosis. Click here to access the list of ICD-10-CM Diagnosis codes that have a PDGM classification.


Medicare provides this resource. It includes fee for service info.


The following are some of the guidelines that CMS spelled out in the November 2018 Federal Register that must be followed for coding under PDGM.

  • Whenever possible, the most specific code that describes a medical disease, condition, or injury should be documented.
    • Generally, ‘‘unspecified’’ codes are used when there is lack of information about location or severity of medical conditions in the medical record.
    • Provider is to use a precise code whenever more specific codes are available.
  • If additional information regarding the diagnosis is needed, the HHA is to follow-up with the referring provider in order to ensure the care plan is sufficient in meeting the needs of the patient.
  • Vague principal diagnosis does not clearly identify the primary reason for home health, and subsequently leads to ambiguous resource use.
  • A home health clinician should not report an ‘‘unspecified’’ code if that clinician can identify the laterality or site of a condition.
  • Many symptom codes, such as pain or contractures cannot be used as the primary diagnosis: For example, 5, Low back pain or M62.422, Contracture of muscle, right hand, although site specific, do not indicate the cause of the pain or contracture. In order to appropriately group the home health period, an agency will need a more definitive diagnosis indicating the cause of the pain or contracture, as the reason for the skilled care.
  • R Codes (which are symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified) are not allowed as a primary diagnosis, except for a few dysphagia codes. In the CY 2020 Final Rule, CMS determined that given the current lack of other definitive diagnoses to describe certain forms of dysphagia, the R-codes to describe dysphagia would be acceptable for reporting the primary reason for home health services. Therefore, the following R-codes will be assigned to the Neuro Rehab clinical group:
    • R13.10, R13.11, R13.12, R13.13, R13.14 & R13.19 – Multiple Dysphagia codes
  • CMS recognizes that the coding guidelines allow for the reporting of signs, symptoms, and less well-defined conditions, however, HHAs are required to establish an individualized plan of care in accordance with the home health CoPs at § 484.60.
  • CMS believes that the use of symptoms, signs, and abnormal clinical and laboratory findings would make it difficult to meet the requirements of an individualized plan of care.
    • Clinically it is important for home health clinicians to have a clearer understanding of the patients’ diagnoses in order to safely and effectively furnish home health services.
    • For patient safety and quality of care, it is important for a clinician to investigate the cause of the signs and/or symptoms for which the referral was made.
    • This may involve calling the referring physician to gather more information in order to establish the underlying cause.
  • Muscle weakness is another unacceptable code as a Primary Diagnosis under PDGM. CMS has stated that:
    • M62.81, ‘‘Muscle weakness, generalized’’ is extremely vague.
    • Generalized muscle weakness, while obviously a common condition among recently hospitalized patients does not clearly support a rationale for skilled services and does not lend itself to a comprehensive plan of care.
    • If there is not an identified cause of muscle weakness, then it would be questionable as to whether the course of therapy treatment would be in accordance with accepted professional standards of clinical practice.
    • CMS identified ‘‘muscle weakness (generalized)’’ as a nonspecific condition that represents general symptomatic complaints in the elderly population.
  • S and T codes
  • There are many of the S and T codes where the fracture and/or injury is unspecified, but the site is specified.
    • CMS maintains that the site of injury and/or fracture should be identified; however, the treatment or intervention would likely not change based on the exact type of injury or fracture.
    • Many of these codes are appropriate to group into a clinical group, and are assigned to either the musculoskeletal group or the wounds group.
With the PDGM Final Rule CMS posted a complete list of ICD–10–CM codes and their assigned clinical groupings.

  • Based on the primary diagnosis, each 30-day period is placed into one of the 12 clinical groupings – HHAs should be familiar with codes that are used to group 30- day periods of care into the 12 clinical groupings.
  • If the primary diagnosis does not fit into one of the 12 clinical groups in the payment model, this is considered a “Unacceptable Diagnosis”.
Coding is critical as two of the five categories for a PDGM HIPPS code results from diagnoses in the primary and secondary spots. PDGM includes comorbidities, which are defined as medical conditions coexisting with a principal diagnosis

  • There are 14 subgroups that can receive a low comorbidity adjustment
  • There are 31 High Comorbidity Adjustment Interaction Subgroups, however, 20 of the subgroups have interactions with either a non-pressure chronic ulcer or with a pressure ulcer

How to Bill Medicare for all Home Health Eligible Claims.

Medicare provides for 3 methods of reimbursement for Physicians who
refer patients to a Medicare Certified Home Health Agency:

1. Physician Certification (Billing Code G0180)
Physician Certification of Home Health Plan of Care is defined as physician
services for initial certification of Medicare-covered home health services

2. Physician Re-Certification (Billing Code G0179)
Physician re-certification is used when the physician signs the Plan of Care
(Form 485) to re-certify a patient for home health services. A physician will
re-certify a patient after a 60 day certification period.

3. Physician Care Plan Oversight (CPO) (Billing Code G0181)
Physicians can bill for 30 minutes of Care Plan Oversight that includes
supervision of a complicated patient and requires extensive review /revision
of care plans, review of laboratory or study results, phone calls to other
health professionals, and other activities associated with the patient’s home
health care.







 
Last edited:
Hi, how do I find the documentation requirements for home health certification codes G0180 & G0179?
 
Here is an article I found which discusses these codes in more detail.

When a Home Health patient is determined to need services of a home health agency (HHA), and the codes available for billing those are G0179 – G0182.

You can use these once every 60 days.

The short description for G0179 is “MD recertification HHA PT” and can only be claimed once every 60 days unless the patient starts a new episode within 60 days, but this is rare. Otherwise, it is only used once per certification period. G0179 includes time for contact with the HHA and review of patient status reports.

The short description for G0180 is “MD certification HHA patient.” G0180 is used for the initial certification when the patient has not received Medicare-covered home health services for over 60 days. It also cannot be used along with the code G0181 on the same date of service.


Please refer to the CMS resource here:



 
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Our free weekly email for home health coders is filled with home health coding tips and a chance to win a $10 Starbucks e-card.
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Medicare Hospice Payment System & Coverage​

Medicare patients who elect hospice must meet these requirements:
  • Be Part A eligible
  • Be certified as terminally ill with medical prognosis of 6 months or less to live if the illness runs its normal course
  • Use the Medicare-approved hospice program
  • Sign the hospice election statement
  • Waive all terminal illness and related conditions coverage rights unless the hospice arranges or delivers it
We pay covered benefits unrelated to terminal prognosis.

Home Health Prospective Payment System & Coverage​


The Bipartisan Budget Act of 2018 included several home health payment reform requirements. These requirements eliminated case-mix adjustments to therapy thresholds and changed the home health payment unit from a 60-day episode to a 30-day period. CMS developed the Patient-Driven Groupings Model (PDGM). It relies on clinical characteristics and other Medicare patient information to place home health care periods into meaningful payment categories. The PDGM is effective for 30-day care periods that began on or after January 1, 2020.
✤ Home Health Service Qualifications
We cover home health services if:
  • Patient’s eligible for home health service coverage (section 30 of Medicare Benefit Policy Manual, Chapter 7)
  • Home Health Agency (HHA) providing services has valid Medicare Program agreement to participate
  • HHA submits a covered services claim
  • Services provided aren’t otherwise excluded from covered services

Patient Eligibility​

Patients are eligible for Medicare home health services if they:
  • Enrolled in Medicare Parts A and B
  • Confined to home (homebound)
  • Need intermittent Skilled Nursing (SN) care, Physical Therapy (PT), or Speech-Language Pathology (SLP) services
  • Continually need Occupational Therapy (OT)
  • Under a physician’s or allowed practitioner’s care
  • Get services under a home health Plan of Care (POC) a physician or allowed practitioner established and periodically reviews
Consider an individual confined to home if they meet these criteria:

Criterion 1​

Individual must meet 1 of these requirements:
  • Need supportive devices like crutches, canes, wheelchairs, and or walkers, use special transportation, and or must get another person’s help to leave their residence because of illness or injury
  • Have a condition where leaving their home isn’t medically advised
If the individual meets 1 Criterion 1 condition, they must also meet all Criterion 2 requirements.

Criterion 2​

  • Individual can’t normally leave home
  • Leaving home requires a considerable and taxing effort
Consider a person “homebound” if they don’t leave their home often or if they only leave for a short time for health care services, religious services, adult day care, or other unique or infrequent events (for example, funeral, graduation, barber, or hairdresser services).

Homebound Examples:​

  • Person who’s blind or has dementia and needs someone’s help to leave home
  • Patient who returns home after surgery and a physician or allowed practitioner has restricted their actions to specified and limited activities (like only getting out of bed for a specified length of time or only walking stairs once a day)
  • Person with a mental disorder who refused to leave home or whose physician or allowed practitioner considers it unsafe to leave home unattended, even if the individual has no physical limitations

Skilled Therapy​

We cover skilled therapy services to maintain the patient’s current condition or to prevent or slow further deterioration. Services must be:

  • Complex (safely and effectively done by a skilled therapist or therapist assistant supervised by a skilled therapist)
  • Consistent with nature and severity of illness or injury and patient’s particular medical needs, including reasonable services in amount, frequency, and duration
  • Specific, safe, and effective treatment for patient’s condition

Skilled Nursing​

We cover SN care (other than solely venipuncture for getting a blood sample) when:

  • Patient needs registered nurse or licensed vocational nurse specialized judgment, knowledge, and skills (when regulations allow)
  • Patient’s current condition requires SN services to maintain their current condition or prevent or slow further deterioration
Document measurement results for each therapy discipline you order for patients in their clinical record and reassess the patient at least every 30 days.

We cover these skilled care services if the patient requires them and the physician or allowed practitioner delivers them safely and effectively.

Intermittent Skilled Nursing Care​

We define intermittent SN care as care needed less than 7 days each week or less than 8 hours each day, for periods of 21 days or less (with extensions in exceptional circumstances requiring more limited and predictable care).

To meet intermittent SN care requirements, patients must have a medically predictable recurring SN service need. Typically, a patient meets this requirement if they need a SN service at least once every 60 days.

Home Health Aide​

We cover home health aide services like:

  • Personal care
  • Help with activities that support SN services
  • Prosthetic or orthotic device personal care
To provide these services, a home health aide must:

  • Be certified with competency evaluation requirements
  • Provide hands-on personal care or services that help treat patient’s illness or injury, and or maintain patient’s health
  • Do tasks allowed only under state law
Orders for home health aide services must show how often patients need these services. Do on-site supervision at least every 14 days if the patient gets SN, PT, OT, or SLP services. In rare instances outside the HHAs control, we allow 1 virtual supervisory visit per 60-day care episode. You must detail the situation in the patient’s medical record.

Occupational therapists can complete the initial and comprehensive patient assessment when ordered with another rehabilitation therapy service (SLP or PT) but not SN services.


Medical Social Services​

We cover medical social services when:

  • POC explains why only a qualified medical social worker or social work assistant supervised by a qualified medical social worker can provide needed services safely and effectively
  • Services resolve social or emotional problems that get in the way of effective treatment of a patient’s medical condition or recovery rate
We define Medicare home health remote patient monitoring as:

  • Collecting physiologic data (for example, electrocardiogram [ECG], blood pressure, glucose monitoring) digitally stored and or sent by patients or caregivers or both to HHAs
  • Visits to patient home solely to supply, connect, and or train patient on remote patient monitoring equipment, without providing another skilled service aren’t separately billable; HHAs may allow remote patient monitoring as an administrative cost if remote patient monitoring supplements the care planning process
Read more here:
 
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