AHIMA says HCFA’s coding in proposed PPS may be flawed

By MATTHEW HAY

HHBR Washington Correspondent

WASHINGTON – The American Health Information Management Association (AHIMA; Chicago) told the Health Care Financing Administration (HCFA; Baltimore) that because diagnostic coding has been of little importance in the home health setting in the past, it fears the accuracy of the coded data used to develop the diagnostic component of the prospective payment system (PPS) classification system may be seriously flawed.

"We believe that the diagnosis codes reported for home care are of such poor quality as to be of no value in the development of the PPS," AHIMA argued in its comments submitted to HCFA Dec. 20.

The association argued that because many home health patients have multiple diagnoses, it is important for the PPS to clearly define primary home care diagnosis.

"If the primary reason for the need for home care is not one of the diagnostic categories impacting case-mix classification, but the patient has a secondary diagnosis that does fall into one of these diagnostic categories, this diagnosis may be reported as the primary home care diagnosis in order to upcode’ to a higher home health resource group," AHIMA said. "To prevent inappropriate upcoding, it is very important for home health agencies to clearly understand how to identify the primary home care diagnosis."

The association told HCFA that it was also "very concerned" by the OASIS diagnosis reporting requirement that allows only three-digit ICD-9-CM category codes to be reported. AHIMA said the lack of specificity in code assignment has a "severe adverse impact" on clinical severity data adversely impacts the design of the home health classification system.

For example, AHIMA said, category 250 includes specific codes describing the full range of diabetic severity, from a non-insulin-dependent diabetic with no complications to an insulin-dependent diabetic with severe complications. However, the differences in clinical severity can not be identified when only category code 250 is reported, AHIMA added.

The association told AHCFA it is also concerned that OASIS reporting requirements do not allow the reporting of V codes. It noted that under the national official coding guidelines approved by HCFA, the ICD-9-CM codes in the V code section are often the most appropriate primary diagnosis codes for the home health setting.

For example, AHIMA noted, official coding guidelines say acute fracture codes are not to be reported in the home health setting because the fracture has already received restorative treatment. Instead, home health agencies should report the appropriate V code describing the aftercare being provided, such as dressing changes or rehabilitative therapy.

"By not allowing the reporting of V codes in those situations where they have been deemed most appropriate by the official coding guidelines, the consistency and uniformity of national healthcare data are being adversely affected, resulting in data that are of poor quality and little value," AHIMA said.

In other areas, AHIMA said it was pleased that the length of an episode under the proposed PPS coincides with time frames required for OASIS reporting and completion of the plan of care, but argued that the partial episode payment adjustment leaves room for confusion. "Within the 60-day time frame, the patient may change his or her mind, and the physician will re-start home health services with either the same or a different agency," argued AHIMA. "This type of situation does not appear to be covered by the description of intervening events that result in a partial episode payment adjustment."

The association said it is also concerned about an across-the-board payment adjustment based solely on number of visits. "Exclusion of cases with a low number of visits from the case-mix system will result in incomplete and skewed case-mix data, which will have a negative impact on the quality of home health data," AHIMA argued. Moreover, exclusion of certain categories from a PPS "negates the fundamental principles" underlying prospective payment, the association added.