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DX Code Changes

October brings fall weather and starts the transition into seasonal celebrations. For home health agencies, it also begins a bit of chaos and headaches for diagnosis coding. This is because some old diagnosis codes that we have been using for years are no longer effective as of October 1, 2022. This year there were more than 1,400 coding changes.

287 codes have been deleted and are no longer effective as of October 1, while 1,176 new codes have been implemented to replace these deleted codes. To see these changes, you will need a new diagnosis coding manual. As you may know each year, diagnosis coding vendors publish new books with all the changes. Unless you ordered a new book, you will not receive any notification from your publisher.

What does this mean for you and your agency? Diagnosis codes are valid for Medicare and Medicaid based on the FROM date of the Claim, and the Effective date of the OASIS (M0090). This means that claims, Plans of Care, Supplementals, and OASIS that start on or before 9/30 will use the OLD diagnosis codes, but any claims, Plans of Care, Supplementals, and OASIS that start on or after 10/1 will need the NEW diagnosis codes.

This used to cause all kinds of problems with PPS because agencies would have recertifications that occurred on or before 9/30 for a 60-day episode that started on or after 10/1. Fortunately, PDGM broke the requirement for OASIS diagnosis codes to be the same as the diagnosis codes that appear on the Plan of Care and Claim. Thus, agencies can be compliant with all documents but may require diagnosis coding changes between documents. Specifically, the Recertification assessment with an M0090 date prior to October 1, will require the old diagnosis codes and the Plan of Care and Claim will need the new diagnosis codes, provided it starts on or after October 1.

All 60-day episodes that span September/October will require a review of the diagnosis codes on the 2nd 30-day claims that begin on or after October 1. For all of these 2nd 30-day claims, an agency will need to generate a Supplemental on or after October 1 in order to enter the new diagnosis code which are replacing deleted diagnosis codes that expired on September 30.

There are three specific diagnosis codes that will REQUIRE a search of the documentation (H&P, F2F, Progress Note) or a query of the physician(s) to get additional information to correct the code. Most diagnosis codes have a default code that is to be used when insufficient information is present. For example, Chronic Kidney Disease stated as Stage 3 has N18.30, N18.31, or N18.32. N18.30 is the default code if the physician does not specify whether the patient has Stage 3A or 3B.

The three codes that will be problematic for dementia patients will be F01.51 – Vascular dementia, F02.81 – Dementia in other diseases, and F03.91 – Unspecified dementia. Each of these codes addresses when the patient has one of these types of dementia with behavioral issues. These three codes on or before September 30 are the default code if the physician does not state the behavioral manifestations. The 2023 version of these codes have NO default code to use to specify the behavioral manifestation.

Starting on October 1, agencies will be required to search the documentation or query the physician to identify the behavioral manifestation of dementia. The qualifying behavioral manifestations are:

  • Without behavioral, psychotic, mood disturbances and anxiety
  • With agitation
  • With other behavioral disturbances
  • With psychotic disturbance
  • With mood disturbances
  • With anxiety

New coders may be tempted to use them without behavioral, psychotic, mood disturbances, and anxiety, but this code is specifying the patient has no behavioral disturbances and thus prevents this code from being used if the physician states the patient does have behavioral or other disturbances. The second option that new or inexperienced coders would jump at would be the “With other behavioral disturbances”. Unfortunately, this is not an option stating that none of the other options apply, but instead in Coding Guideline terms, means that it is another stated disturbance that does not fall in the other available categories. In Coding guideline terms, this option would have to state Not Elsewhere Coded/NEC.

Contrary to popular belief, physicians are not trained in diagnosis coding any more than clinicians are, this is why they have diagnosis coders and billers, just like home health agencies. This means your physicians will NOT be aware of the need to document the type of behavioral disturbances and thus will require, in almost all cases, the coder, clinician, or biller to call and ask the physician for the disturbances. In some cases, physicians document Sundowning, hallucinations, etc., but in most cases, they just state behavioral disturbances.

Many would turn to the nurse who assessed the patient and spoke with the family/caregivers to locate the type of behavioral disturbances, but this is NOT an allowed practice in the use when selecting the correct diagnosis code. Coding Guidelines state that with the exception of BMI calculation and Pressure Ulcer Staging, physicians must provide the diagnosis. It IS permissible to use these findings when speaking to the physician to have them confirm a particular behavioral disturbance.

Once the behavioral disturbance is known, it will then be possible to select the Severity to locate the most accurate code. Severity is broken down into four categories; Unspecified (the default if not specified), Mild, Moderate, and Severe.

Communication with the physician will be necessary to locate the correct specificity for these 3 codes which have now expanded to a total of 72 different possible codes. These are the reasons it is essential to have a trained diagnosis coder to enter the codes into your OASIS and Plan of Care. If your agency struggles with these changes, please be aware that HealthCare Synergy has outsourced coders that can provide short- or long-term coding for your agency.

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