Proper Coding of Post-Surgical Admissions
on Home Health Claims
HEALTH CARE FINANCING ADMINISTRATION
HCFA Clarification: "Misuse of Trauma Codes in Home Health PPS Claims" (March 28, 2001)
Following last week's list serve message [see below] about misuse of trauma codes in home health PPS claims, we received a number of questions about diagnosis coding using surgical complications codes. For clarification, we present below one of those questions, followed by our answer.
Question: We read with interest your message to the HH PPS list regarding proper coding for home health diagnoses. This is a constant challenge to us all, and we are constantly looking for suggestions to tighten up our coding so it is accurate and appropriate. I continue to have a concern regarding the coding for the "open wound". For example, we are seeing the patient for a post op wound infection after a gall bladder removal. The Plan of Care instructions are regarding the assessment and care of the wound. When we code the primary diagnosis as "cholelithiasis" on the OASIS and POC, we would then also code the surgical procedure for the POC. It is our practice to also code the open wound/wound infection, as a secondary diagnosis. However, the open wound or wound infection codes, as well as wound
dehiscence, are 900 codes which are in the book under Injury & Poisonings. What are we to use for these codes when the code book refers us back to this chapter, yet your message clearly states that this is inappropriate? The HIM 11 clearly tells us to use the "primary reason for home care services" as the primary diagnosis; yet in the above scenario, the primary reason for the care to the patient is wound related. Thanks in advance for any clarification you can give.
Answer: If the primary reason for home care is an infected surgical wound, the code for an infected surgical wound (which comes from 996-999, complications of surgical and medical care, not elsewhere classified) is appropriate as the primary diagnosis. The list serve notice was primarily directed at correcting the misuse of the open wound codes. The complications codes have always been available but in the past they haven't received much attention. For example, that group of codes has hardly been used in Medicare home health claims in recent years. This fact gives us pause, and makes us caution you to ensure that you truly have a complication before you use it as the primary or any other diagnosis. The codes for complications of medical and surgical care should ONLY be reported when a complication has been documented by the patient's physician. If not, then you are usually obliged to code what OASIS calls the "relevant medical diagnosis" or "underlying diagnosis". The October 2, 2000, Program Memorandum A-00-71 provides examples of post-surgical cases where the condition that led to the surgery is coded (because V-codes are not allowed). The same logic applies to post-surgical-wound care (because, other than V-codes, there are no diagnosis codes for uncomplicated surgical wounds). Your use of cholelithiasis as the primary diagnosis would be correct in the uncomplicated case.
"Misuse of Trauma Codes in Home Health PPS Claims"
(March 21, 2001)
A number of home health agencies are incorrectly using the ICD-9-CM diagnosis codes when reporting the primary diagnosis for post-surgical admissions on the OASIS and UB-92. They are using diagnosis codes for trauma instead of reporting the relevant medical diagnosis. These trauma codes, which come from the ICD-9-CM chapter "Injury and Poisoning", are reserved for injuries from accidents and intentional violence. They include categories for fracture (800-829), dislocation, sprains, and strains (830-849), internal injuries (860-869), open wounds (870-897), and other injuries and burns (900-999). This means that surgeries and amputations performed for treating disease are not coded from the "Injury and Poisoning" section. The only common condition in home health where a trauma code is used is fracture due to a fall, other accident, or intentional injury. Therefore, in most cases hip fracture and other fractures treated surgically or otherwise ARE correctly coded with a trauma code (using one of the codes for fracture, 860-869).
V-codes are not allowed on OASIS, even though they are the most appropriate code to use in many post-surgical wound cases, according to ICD-9-CM coding guidelines. Rather than using V-codes, the OASIS instructions indicate the agency should code the primary diagnosis from the condition responsible for the surgery. This raises a problem for diagnosis coding in many post-surgical wound care cases. If the agency selects a code for the condition that led to the surgical wound, the result may be a diagnosis that the patient no longer has. Nevertheless, in many if not most post-operative admissions to home health, when a patient is admitted to home care mainly for surgical wound assessment and treatment, the condition responsible for the surgery must be used as the primary diagnosis. For example, on OASIS, it is correct to report spinal stenosis (724.0x) as the primary diagnosis in the case of a successful laminectomy performed to treat it, even if the patient after surgery is considered cured.
Agencies that have erroneously coded disease-related post-surgical cases with a trauma diagnosis should submit a corrected claim to ensure accurate payment.
Also, please note the following guidance issued in Program Memorandum A-00-71. This PM stipulates that "the principal diagnosis must match on the physician certified POC, the OASIS and the Uniform Billing Form-92 (UB-92). In addition, V codes are not acceptable as principal or first secondary diagnoses but could be recorded in item 21 entitled Orders for Discipline and Treatments. The ICD-9-Cm coding guidelines should be followed in assigning an appropriate V code." Possible appropriate V-codes when the patient requires post-surgical wound care include V54.x, V58.4x, and V58.3.