MAC Legacy Advanced Coding through the PDGM Looking …...coding principles as they relate to PDGM in Home Care. Learning Objectives • Enhance the knowledge of the learner on the

2021 SW Series ‐ Coding Workshop Day 2 04/22/2021

(C) MAC LEGACY. All Rights Reserved 1

MAC Legacy Advanced Coding through the PDGM

Looking GlassNanette Minton, RN, HCPCA, HCS-D, HCS-H

Course OutlineThis 4-hour course will provide education regarding intermediate and advanced coding principles. The learner will have the opportunity to work through complicated scenarios to apply the knowledge. This course provides a focus on the education required to apply the coding principles as they relate to PDGM in Home Care.

Learning Objectives• Enhance the knowledge of the learner on the impact of coding on Clinical Groupings and

Comorbidity Adjustments.• Educate the learner on accurate, ethical coding to determine which codes apply and how

they interact to affect reimbursement.



Chapter 1: Infectious Diseases—Advanced Concepts

Sepsis due to a post-procedural infection • In cases of sepsis due to post-procedural infection, base the code assignment on the provider’s

documentation of the relationship between the infection and the procedure. • For such cases, the post-procedural infection code, such as listed below should be coded first,

followed by the code for the specific infection.• T80.2, Infections following infusion, transfusion and therapeutic injection;• T81.44, Sepsis following a procedure; • T88.0, Infection following immunization; or • O86.0-, Infection of obstetrical surgical wound, should be coded first, followed by the code for the specific

infection. If the patient has severe

• If the patient has severe sepsis the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.


Sepsis and severe sepsis associated with a noninfectious process• If sepsis or severe sepsis is documented as associated with a noninfectious condition,

such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious process is sequenced first, followed by the code for the resulting infection. • If severe sepsis is present, a code from subcategory R65.2 should also be assigned with

any associated organ dysfunction(s) codes. • It is not necessary to assign a code from R65.1, Systemic inflammatory response

syndrome (SIRS) of non-infectious origin, for these cases.


MRSA and MSSA • When a patient is diagnosed with an infection that is due to methicillin resistant

Staphylococcus aureus (MRSA) or Methicillin susceptible Staphylococcus aureus (MSSA), and that infection has a combination code that includes the causal organism, assign the appropriate combination code for the condition (e.g., A41.02, Sepsis due to MRSA). • Do not assign code B95.62, Methicillin resistant Staphylococcus aureus infection, as the

cause of diseases classified elsewhere, or Z16.11, Resistance to penicillins, as additional diagnoses. • If a patient has a diagnosis of pneumonia due to Methicillin susceptible Staphylococcus

aureus, code only the combination code J15.211 without an additional code from B95.61.




MRSA and MSSA • When there is documentation of a current infection (e.g., wound infection, stitch abscess,

urinary tract infection ) due to MRSA, and that infection does not have a combination code that includes the causal organism: • Assign the appropriate code to identify the condition along with a code from B95.62,

Methicillin Resistant Staphylococcus Aureus (MRSA), or B95.61 Methicillin Susceptible Staphylococcus Aureus (MSSA), as the cause of the diseases classified elsewhere for the MRSA or MSSA infection. • Do not assign a code from subcategory Z16.11, Resistance to penicillins, along with the

B95.62 code.


MRSA and MSSA • The condition or state of being colonized or carrying MSSA or MRSA is called colonization or carriage,

while an individual person is described as being colonized or being a carrier.• Colonization is not necessarily indicative of a disease process or as the cause of a specific condition the

patient may have unless documented as such by the provider. • Colonization means that MSSA or MRSA is present on or in the body without necessarily causing illness.

A positive MRSA colonization test might be documented by the provider as “MRSA positive screen” or “MRSA nasal swab positive.” • Assign code Z22.322, Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus, for patients

documented as having MRSA colonization. • Assign code Z22.321, Carrier or suspected carrier of Methicillin susceptible Staphylococcus aureus, for patients

documented as having MSSA colonization. • If the patient is stated to have a history of MRSA, use code Z86.14. • If a patient is documented as having both MRSA colonization and infection, you may assign both code Z22.322, Carrier or

suspected carrier of MRSA, and a code for the MRSA infection.

Chapter 1: Infectious Diseases Scenario

• Patient referred to home care services for weekly access of implanted port to maintain site access. Patient is undergoing treatment for Lung cancer to the left lower lobe with metastasis to the spinal cord but is currently on hold. Patient also has comorbidities of HTN, DM, mild CKD and takes Byetta and Lantus. • Code this scenario:




• Z45.2-Encounter for adjustment and management of vascular access device• C34.32-Malignant neoplasm of lower lobe, left bronchus or lung• C79.49-Secondary malignant neoplasm of other parts of nervous system• I12.9-Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease,

or unspecified chronic kidney disease• E11.22-Type 2 diabetes mellitus with diabetic chronic kidney disease• N18.2-Chronic kidney disease, stage 2 (mild)• Z92.21-Personal history of antineoplastic chemotherapy• Z79.4-Long term (current) use of insulin• Z79.899-Other long term (current) drug therapy


• Z45.2--This code as primary or first secondary places the patient into the complex nursing primary grouper. • Use the code as primary only if the care of the infusion line is the only care provided and

the underlying condition is not being treated. This code may be placed as a secondary for Medicare data purposes.

Chapter 1: Infectious Diseases

• A 62 year old female patient is referred to home health following removal of right knee prosthesis due to MRSA infection and the insertion of an antibiotic spacer. SN ordered for administration of IV antibiotics and PT for instruction regarding limited range of motion, gait abnormality, and home safety. Surgery will be scheduled for a new prosthesis once the infection has resolved. The patient also has a diagnosis of DM and requires daily insulin. • Code this scenario:



Chapter 1: Infectious Diseases

• T84.53XA-Infection and inflammatory reaction due to internal right knee prosthesis, initial encounter• B95.62-Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified

elsewhere• E11.9-Type 2 diabetes mellitus without complications• Z45.2-Encounter for adjustment and management of vascular access device• Z79.4- Long term (current) use of insulin• Z79.2-Long term (current) use of antibiotics• Z89.521-Acquired absence of right knee

Chapter 2: Neoplasms—Advanced Concepts

Coding and sequencing of complications • When admission/encounter is for management of anemia associated with the malignancy, and

the treatment is only for the anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease). • When the admission/encounter is for management of an anemia associated with an adverse

effect of the administration of chemotherapy, immunotherapy or radiation and the only treatment is for the anemia, the anemia code is sequenced first. • When the admission/encounter is for the management of dehydration due to the malignancy and

only the dehydration is being treated (intravenous hydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.


Pathological fracture due to a neoplasm • When an encounter is for a pathological fracture due to a neoplasm, and the focus of

treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by the code for the neoplasm from Chapter 2. • If the focus of care is the neoplasm with an associated pathological fracture, the

neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture.




Patients with long-term use of agents affecting estrogen receptors and estrogen levels • Codes revolving around long-term use of agents affecting estrogen receptors and estrogen

levels, such as SERMS, aromatase inhibitors and other agents, are found in the Z79.81-subcategory. • The use of long-term prophylactic agents to prevent recurrence of disease raises questions as

to when treatment is actually complete. • Instructions at the Z79.81 subcategory include: ‘Code first, if applicable’: malignant neoplasm of

breast (C50-) or malignant neoplasm of prostate (C61) and ‘Use additional code, if applicable, to identify’: estrogen receptor positive status (Z17.0); family history of breast cancer (Z80.3); genetic susceptibility to cancer (Z15.0-); personal history of breast cancer (Z85.3); personal history of prostate cancer (Z85.46) and/or postmenopausal status (Z78.0).


Malignant neoplasm associated with a transplanted organ • The incidence of cancer in transplanted organs has increased. • A malignant neoplasm of a transplanted organ should be coded as a transplant

complication. • Assign first the appropriate code from category T86.-. Complications of transplanted

organs and tissue, followed by code C80.2, Malignant neoplasm associated with transplanted organ. • Use an additional code for the specific malignancy


Leukemia, multiple myeloma and malignant plasma cell neoplasm • The categories for leukemia and category C90, Multiple myeloma and malignant plasma

cell neoplasms, have codes indicating whether or not the leukemia has achieved remission. • There are also codes Z85.6, Personal history of leukemia, and Z85.79, Personal history of

lymphoid, hematopoietic and related tissues. • If the documentation is unclear as to whether the leukemia has achieved remission, the

provider should be queried.



Chapter 2: Neoplasms—Scenario

• A 79 year old woman is admitted to home health for treatment of neoplasm-related pain. She was treated 10 years ago for breast cancer including a bilateral mastectomy, chemo and radiation. The cancer was noted to be resolved. Patient began to have pain to various areas and was diagnosed with bone metastasis from the previous breast cancer. She is a long-time cigarette smoker.• Code this scenario:


• G89.3-Neoplasm related pain (acute) (chronic)• C79.51-Secondary malignant neoplasm of bone• Z85.3-Personal history of malignant neoplasm of breast• Z90.13-Acquired absence of bilateral breasts and nipples• F17.210-Nicotine dependence, cigarettes, uncomplicated• Z92.3-Personal history of irradiation• Z92.21-Personal history of antineoplastic chemotherapy


An 80 year old woman is referred to home health for management of a malignant pericardial effusion that is causing shortness of breath and fatigue. The cause of the pericardial effusion is documented as metastatic melanoma that began on her forehead and spread to both of her lungs, and her liver. Discharge documents indicate she also has hypertensive heart disease and end stage kidney failure. She attends hemodialysis three times a week. Code this scenario:




Pericardial effusion (noninflammatory) I31.3

Secondary malignant neoplasm of right lung C78.01

Secondary malignant neoplasm of left lung C78.02

Secondary malignant neoplasm of liver and intrahepatic bile duct

C78.7

Malignant melanoma of other parts of face C43.39

Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease

I13.11

End stage renal disease N18.6

Dependence on renal dialysis Z99.2

Chapter 3: Diseases of the Blood and Blood-Forming Organs—ScenarioA 65-year-old man is admitted to home health with chronic graft versus host disease that is a complication of a stem cell transplant performed a year ago to treat multiple myeloma. The transplant put his multiple myeloma into remission but he continues to experience diarrhea and desquamative dermatitis, which his doctor diagnosed as manifestations of the chronic graft versus host disease. He'll receive skilled nursing for managing new medications, including multiple new immunosuppressive drugs, and physical therapy for muscle strengthening and stamina.Code this scenario:

Chapter 3: Diseases of the Blood and Blood-Forming Organs—ScenarioComplications of stem cell transplant T86.5

Chronic graft‐versus‐host disease D89.811

Other specified dermatitis L30.8

Diarrhea, unspecified R19.7

Multiple myeloma in remission C90.01

Other long term (current) drug therapy Z79.899



Chapter 4: Endocrine, Nutritional and Metabolic Diseases—Advanced Concepts

Complications due to insulin pump malfunction • Underdose of insulin due to insulin pump failure should be assigned with a specific code

from subcategory T85.6 (Mechanical complication of other specified internal and external prosthetic devices, implants and grafts), as the principal or first-listed code. • It should be followed by code T38.3x6- (Underdosing of insulin and oral hypoglycemic

[antidiabetic] drugs). • Additional codes for the type of diabetes mellitus and any associated complications due to

the underdosing should also be assigned


Overdose of insulin due to insulin pump failure• The principal or first-listed code for an encounter due to an insulin pump malfunction

resulting in an overdose of insulin should be:

• T85.6-(Mechanical complication of other specified internal and external prosthetic devices, implants and grafts), followed by code

• T38.3x1- (Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional).


• Include as many codes within a particular category as are necessary to describe all the complications of the diabetes. • They should be sequenced based on the reason for a particular encounter.• Assign as many codes from Categories E08 – E13 as needed to identify all the associated

conditions.



Chapter 4: Endocrine, Nutritional and Metabolic Diseases—Advanced Concepts• For example, for a patient who has Type 2 diabetes mellitus and diabetic peripheral angiopathy

and diabetic gastroparesis, report codes:• E11.5- (Diabetes with diabetic angiopathy) and • E11.43 (Diabetes with diabetic gastroparesis).

• If multiple manifestations apply to a specific body system, then sequence them accordingly. For example:• For a patient who has diabetic peripheral angiopathy and gangrene, you would assign E11.52.

• Code Z79.4 (long-term [current] use of insulin) also is reported as an additional diagnosis for patients who have Type 2 diabetes, secondary diabetes, or an unspecified type of diabetes who routinely use insulin.• Code Z79.4 is not reported for patients with Type 1 diabetes. Code Z79.84 (oral

antidiabetic/hypoglycemic drugs) is also available to report as an additional diagnosis when applicable.


2021 Update to Official Guidelines for Coding and Reporting• If the patient is treated with both insulin and an injectable non-insulin antidiabetic drug,

assign codes Z79.4, Long-term (current) use of insulin, and Z79.899, Other long term (current) drug therapy. • If the patient is treated with both oral hypoglycemic drugs and an injectable non-insulin

antidiabetic drug, assign codes Z79.84, Long-term (current) use of oral hypoglycemic drugs, and Z79.899, Other long-term (current) drug therapy.


2021 Update to Official Guidelines for Coding and Reporting• Liraglutide (Victoza) once daily injection

• Exenatide (Byetta) twice daily injection

• Exenatide extended release pen (Bydureon) once weekly injection

• Albigltide (Tanzeum) once weekly injection

• Dulaglutide (Trulicity) once weekly injection

• Non-insulin injectable medications mimic the effect of the body’s own ‘incretin hormones’ which help to manage blood glucose levels after meals.




Secondary diabetes mellitus • Codes under categories E08 (Diabetes mellitus due to underlying condition), E09 (Drug or

chemical induced diabetes mellitus) and E13 (Other specified diabetes mellitus) all identify secondary diabetes.• Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis,

malignant neoplasm of the pancreas, pancreatectomy, adverse effect of drug or poisoning). • Like primary diabetes mellitus, there are combination codes to identify any

complications/manifestations due to secondary diabetes.


Assigning and sequencing secondary diabetes codes and its causes• The sequencing of the secondary diabetes codes in relationship to codes for the cause of the diabetes is

based on the Tabular instructions for E08, E09 and E13.

Secondary diabetes due to drugs • Secondary diabetes may be caused by an adverse effect of correctly administered medications,

poisoning or sequela of a poisoning.•

Secondary diabetes due to pancreatectomy • For post pancreatectomy diabetes mellitus (lack of insulin due to the surgical removal of all or part of

the pancreas), assign code E89.1 (Postprocedural hypoinsulinemia), then assign a code from category E13, followed by a code from subcategory Z90.41- (Acquired absence of pancreas).


Coding Diabetes after a Pancreas Transplant • After the transplant, diabetes may no longer be an issue, but lingering manifestations may be. • Code as you would any patient with diabetic complications. • Assign a code from E11 with the appropriate body system to identify any specific manifestations. • The patient still has complications associated with the diabetes because the transplant did not

resolve the manifestations of diabetes, even though it did resolve the diabetes. • The manifestations require that diabetes be coded as the etiology even if the patient no longer

has diabetes. • Also code Z94.83, Organ or tissue replaced by transplant, pancreas.



Chapter 4: Endocrine, Nutritional and Metabolic Diseases—Scenario • A patient is referred for skilled nursing, occupational and physical therapy after being

diagnosed with neuropathy due to long-term alcohol dependence, which his physician states is in remission. Prior to these diagnoses, he had been diagnosed with polyneuropathy due to diabetes and PVD. His diabetes is diet controlled.

• Code This scenario:

Chapter 4: Endocrine, Nutritional and Metabolic Diseases—Scenario Alcoholic polyneuropathy G62.1

Alcohol dependence, in remission F10.21

Type 2 diabetes mellitus with diabetic polyneuropathy

E11.42

Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

E11.51

Chapter 4: Endocrine, Nutritional and Metabolic Diseases—Scenario • The patient has diabetes and multiple stasis ulcers on both calves that extend to the fat

layer and are caused by venous insufficiency. The patient also has peripheral neuropathy and lymphedema. Oral hypoglycemic medication is used for diabetic control. The wound care is the focus of care.

• Code this scenario:



Chapter 4: Endocrine, Nutritional and Metabolic Diseases—Scenario

Encounter for change or removal of nonsurgical wound dressing

Z48.00

Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

E11.51

Venous insufficiency (chronic) (peripheral) I87.2

Non‐pressure chronic ulcer of left calf with fat layer exposed

L97.222

Non‐pressure chronic ulcer of right calf with fat layer exposed

L97.212


E11.42

Lymphedema, not elsewhere classified I89.0

Long term (current) use of oral hypoglycemic drugs

Z79.84

Chapter 4: Endocrine, Nutritional and Metabolic Diseases—Scenario • A 69-year-old morbidly obese woman with a BMI of 37 comes to home health for wound

care to a diabetic foot ulcer on her left heel. The wound has penetrated muscle tissue but there’s no mention of necrosis. The documentation also lists a diagnosis of sick sinus syndrome that is controlled with a pacemaker. She is insulin-dependent.


Chapter 4: Endocrine, Nutritional and Metabolic Diseases—Scenario

Type 2 diabetes mellitus with foot ulcer E11.621

Non‐pressure chronic ulcer of left heel and midfoot with muscle involvement without evidence of necrosis

L97.425

Sick sinus syndrome I49.5

Morbid (severe) obesity due to excess calories E66.01

Presence of cardiac pacemaker Z95.0

Body mass index (BMI) 37.0‐37.9, adult Z68.37

Long term (current) use of insulin Z79.4



Chapter 4: Endocrine, Nutritional and Metabolic Diseases—Scenario • A 38-year-old male patient male patient is admitted with severe malnutrition and anemia

due to neoplastic disease including primary liver cancer. He also requires wound care due to a stage 3 pressure wound of the left ankle. His medical record notes that he is wheelchair bound due to C1-C4 complete quadriplegia secondary to a C1 spinal cord injury causing central cord syndrome. The focus of care is malnutrition.


Chapter 4: Endocrine, Nutritional and Metabolic Diseases—Scenario Unspecified severe protein‐calorie malnutrition E43

Malignant neoplasm of liver, primary, unspecified as to type

C22.8

Anemia in neoplastic disease D63.0

Pressure ulcer of left ankle, stage 3 L89.523

Quadriplegia, C1‐C4 complete G82.51

Central cord syndrome at C1 level of cervical spinal cord, sequela

S14.121S

Dependence on wheelchair Z99.3

Chapter 5: Mental and Behavioral Disorders—Advanced Concepts• Mental and behavioral disorders due to psychoactive substance use ICD-10-CM has

significantly expanded the coding options related to psychoactive substance use. • Codes for psychoactive substance use disorders (codes from subcategories F10.9-, F11.9-,

F12.9-, F13.9-, F14.9-, F15.9- and F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). • The codes are to be used only when the psychoactive substance use is associated with a

physical, mental or behavioral disorder, and such a relationship is documented by the provider, according to coding guidelines.



Chapter 5: Mental and Behavioral Disorders—Advanced Concepts• There is a selection of codes to indicate “in remission” in categories F10-F19

• Utilize FXX.11 to indicate abuse in remission, or • FXX.21 to indicate dependence in remission.

• These codes are assigned only on the basis of physician documentation that the patient is in remission. • Take note of the following guidelines when coding these diagnoses:

• Capture mild substance abuse disorder in early or sustained remission as substance abuse in remission.

• Code moderate or severe substance abuse disorder in early or sustained remission as substance dependence in remission.

Chapter 5: Mental and Behavioral Disorders—Advanced Concepts• When the physician documentation refers to use, abuse and dependence of the same

substance (e.g., alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy:• If both use and abuse are documented, assign only the code for abuse.• If both abuse and dependence are documented, assign only the code for dependence.• If use, abuse and dependence are all documented, assign only the code for dependence.• If both use and dependence are documented, assign only the code for dependence.

• As with all other diagnoses, the codes for psychoactive substance use should only be assigned based on the physician’s documentation and when they meet the definition of a reportable diagnosis.

Chapter 5: Mental and Behavioral Disorders—Advanced Concepts• The definition of other diagnoses is interpreted as additional conditions that affect patient

care in terms of requiring: Clinical evaluation, or Therapeutic treatment, or Diagnostic procedures, or extended length of stay, or Increased nursing care and/or monitoring.• The codes are to be used only when the psychoactive substance use is associated with a

mental or behavioral disorder, and such a relationship is documented by the physician. • Chapter 5 includes many combination codes that combine the psychoactive substance

use with other symptoms such as F10.97 (Alcohol use, unspecified with alcohol-induced persisting dementia) or F10.250 (Alcohol dependence with alcohol induced psychotic disorder with delusions).



Chapter 5: Mental and Behavioral Disorders—Scenario

• An 82-year-old female patient who has experienced multiple CVAs over the previous 12 months presents for home health speech, physical and occupational therapy with diagnoses of multi-infarct dementia due to the prior CVAs, left hemiplegia due to the most recent CVA, hypertension, and early onset Alzheimer’s disease. The dietician was consulted during her recent SNF stay and documented mild malnutrition. The focus of her treatment will be the multi-infarct dementia.• Code this scenario:

Chapter 5: Mental and Behavioral Disorders—Scenario

Other symptoms and signs involving cognitive functions following cerebral infarction

I69.318

Vascular dementia without behavioral disturbance F01.50

Hemiplegia and hemiparesis following cerebral infarction affecting left non‐dominant side

I69.354

Essential (primary) hypertension I10

Alzheimer's disease with early onset G30.0

Dementia in other diseases classified elsewhere without behavioral disturbance

F02.80

Chapter 6: Diseases of the Nervous System-Coding for Pain—Advanced Concepts

• Postoperative pain is based on the physician documentation. • The default code for post-thoracotomy and other postoperative pain not specified as

acute or chronic would be the code for the acute form. • However, routine or expected pain immediately after surgery should not be coded.• Postoperative pain not associated with a specific postoperative complication is assigned

to the appropriate postoperative pain code in G89.



Chapter 6: Diseases of the Nervous System—Advanced Concepts• Postoperative pain associated with a specific postoperative complication (e.g., painful

wire sutures, T81.89) is assigned from chapter 19 (Injury, poisoning, and certain other consequences of external causes). • If appropriate, use an additional code from G89.18 (acute pain) or G89.28 (chronic pain).

Chapter 6: Diseases of the Nervous System—Advanced Concepts• For pain due to devices, implants or grafts, report code T85.84- (pain due to internal prosthetic

devices, implants and grafts, not elsewhere classified). • For complication of a device, implant or graft associated with a specific system, assign a code

for the specific system device, such as implant and graft (T84-T88) from Chapter 19 (Injury, poisoning and other consequences of external causes) as the first-listed diagnosis. • Also, add a code for the pain if it provides additional information. For example, a subsequent

encounter for acute pain due to an infection of a right hip prosthesis is reported as T84.51xD (infection of right hip prosthesis) as the primary diagnosis. • Use an additional code to identify the infection, and you may assign G89.18 to indicate that acute

post-procedural pain has been documented for this patient by the physician as another additional diagnosis.

Chapter 6: Diseases of the Nervous System—Advanced Concepts• There is no time frame defining when pain becomes chronic; • Physician’s documentation should be used to guide use of these codes.• Neoplasm-related pain (G89.3) is assigned to pain documented as being related,

associated or due to cancer, primary or secondary malignancy or tumor, whether the pain is acute or chronic.• Central pain syndrome (G89.0) and chronic pain syndrome (G89.4) are different than the

term “chronic pain” and therefore codes should only be used when the physician has specifically documented this condition.



Chapter 6: Diseases of the Nervous System—Scenario

• A 50-year-old woman, diagnosed with multiple sclerosis for the past 20 years, has decreased visual acuity and some impaired mobility, balance and fine motor control, all of which have been relatively stable for six months. She requires home care for the management of her neurogenic bladder, which is causing urinary retention and incontinence without awareness and is managed with a chronic Foley catheter. She has had several UTIs. A nurse visits every four weeks to change the catheter, perform other care associated with the Foley catheter, monitor for signs of urinary tract infection and perform management of the neurogenic bladder.• Code this scenario:

Chapter 6: Diseases of the Nervous System—Scenario

Neurogenic bladder NOS N31.9

Multiple sclerosis G35

Incontinence without sensory awareness N39.42

Fitting and adjustment of urinary devices Z46.6

Personal history of urinary (tract) infection Z87.440

Chapter 9: Diseases of the Circulatory System—Advanced Concepts

2021 Official Guidelines for Coding and Reporting

• For Chapter 9: Diseases of the Circulatory System, 3) Hypertensive Heart and Chronic Kidney Disease, the bolded words were added:• For patients with both acute renal failure and chronic kidney disease, “the acute renal

failure should also be coded. Sequence according to the circumstances of the admission/encounter.”




Subsequent Acute MI • Assign a code from category I22 when a patient who has suffered a type 1 or unspecified

AMI has a new AMI within the 4 week time frame of the initial AMI. • Use a code from category I22 with a code from category I21. • The sequencing of the I22 and I21 codes depends on the circumstances of the encounter. • Do not assign I22 for subsequent myocardial infarctions other than type 1 or unspecified. • For subsequent type 2 AMI assign only assign I21.A1. • For subsequent type 4 or type 5 AMI, assign only I21.A9, per coding guidelines.


Other Types of Myocardial Infarction • Type 1 myocardial infarctions are assigned to codes I21.0-I21.4. • Type 2 myocardial infarction (myocardial infarction due to demand ischemia or secondary

to ischemic imbalance), is assigned to code I21.A1. • When a type 2 AMI code is described as NSTEMI or STEMI, only assign code I21.A1. • Codes I21.01-I21.4 should only be assigned for type 1 AMIs. • Acute myocardial infarctions type 3, 4a, 4b, 4c and 5 are assigned to code I21.A9, Other

myocardial infarction type.


2021 Official Guidelines for Coding and Reporting• For Chapter 9: Diseases of the Circulatory System, 3) Hypertensive Heart and Chronic

Kidney Disease, the bolded words were added:• For patients with both acute renal failure and chronic kidney disease, “the acute renal

failure should also be coded. Sequence according to the circumstances of the admission/encounter.”



Chapter 9: Diseases of the Circulatory System--Scenario

• The patient developed chest pain, severe shortness of breath, and was hospitalized. Pulmonary scans and arteriograms revealed that more than half of the major pulmonary arteries were occluded; smaller vessels also were obstructed. Pulmonary embolectomy was performed on major vessels. The patient was sent home on Coumadin. The patient has a history of chronic emphysematous bronchitis and hypertension. Home health orders are for wound care, teaching of the disease process, meds and lab draws for PT/INR.



Aftercare following surgery of circulatory system Z48.812

Other pulmonary embolism without acute corpulmonale

I26.99

Chronic obstructive pulmonary disease, unspecified J44.9

Essential primary hypertension I10

Therapeutic drug monitoring Z51.81

Long term use of anticoagulants Z79.01


• A 75-year-old woman comes to home health after developing an ulcer on her calf, which her physician diagnosed as caused by atherosclerosis. The clinician documents that the ulcer is on her right calf, measures two millimeters in depth and four millimeters in diameter, and that it has gone beyond the skin layers into the patient's fatty tissue. The patient also has hypertension. The nurse also documents that while the patient has never smoked, her husband has been a smoker for 35 years, and continues to smoke. Home health will provide wound care.





Atherosclerosis of native arteries of right leg, with ulceration of calf

I70.232

Non‐pressure chronic ulcer of right calf with fat layer exposed

L97.212


Exposure to environmental tobacco smoke Z77.22

Chapter 10: Diseases of the Respiratory System—Scenario

• Patient referred to home care with both emphysema exacerbation due to hospitalization with bacterial pneumonia and new diagnosis of bronchiectasis with exacerbation. Home care focus of care is the still resolving pneumonia and emphysema.


Chapter 10: Diseases of the Respiratory System—Scenario

Emphysema, unspecified J43.9

Unspecified bacterial pneumonia J15.9

Bronchiectasis with acute lower respiratory infection J47.0

Secondary: Long term (current) use of insulin J47.1



Chapter 11: Diseases of the Digestive System—Scenario

• A patient with Parkinson's and dysphagia has cellulitis of the abdominal wall extending from an infected gastrostomy site. Documentation confirmed the culture growth of Staphylococcus aureus without mention of MRSA from the gastrostomy site. Home health will focus on the infection. The patient is taking a 3-week course of oral antibiotics.


Chapter 11: Diseases of the Digestive System—Scenario

Infection of gastrostomy K94.22

Cellulitis of abdominal wall L03.311

Methicillin susceptible Staph aureus infection as the cause of diseases classified elsewhere

B95.61

Parkinson's disease G20

Dysphagia, unspecified R13.10

Long term (current) use of antibiotics Z79.2

Chapter 12: Diseases of the Skin and Subcutaneous Tissue—Advanced Concepts• Your new 66-year-old patient was referred for care of a stage 3 pressure ulcer/injury

on her right buttock and a stage 2 pressure ulcer/injury on her right hip. Skilled nursing has been ordered for wound care. She also has hypertension and is a paraplegic due to an old spinal stroke.




Chapter 12: Diseases of the Skin and Subcutaneous Tissue—Advanced Concepts

Pressure ulcer right buttock, stage 3 L89.313

Pressure ulcer right hip, stage 2 L89.212

Paraplegia G82.20


Dependence on wheelchair Z99.3

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue—Advanced Concepts• Code T84 includes all of the complications of orthopedic prostheses, implants and grafts. • Periprosthetic fractures are not considered complications and can be found in M97. • Subcategory T84.0 includes complications of internal prosthetic joints. Most include the

joint affected, so there is no need to add Z96.6 for the joint unless the complication code does not indicate the joint. • A code from M96.6- or M97.- may provide additional information.

Chapter 14: Diseases of the Genitourinary System—Advanced Concepts

Catheter associated infection• If the infection is caused by the catheter, assign a code from T83.51- (infection and

inflammatory reaction due to urinary catheter). • When T83.51- is used, do not use the Z46.6 code for catheter care. • Follow the T83.51- code with an additional code for the specified infection.



Chapter 14: Diseases of the Genitourinary System—Advanced Concepts

Neurogenic Bladder• Neurogenic bladder or neuromuscular dysfunction of bladder, unspecified normally is

coded N31.9. • There is a note at the N31 category to use an additional code to identify any associated

urinary incontinence (N39.3-, N39.4-). • Another code for neurogenic bladder, G83.4 (Neurogenic bladder due to cauda equina

syndrome) is from Chapter 6, Diseases of the nervous system, but it should not be used unless it is documented or verified with the physician. • Improper use of neurogenic bladder codes is a red flag and typically leads to denials. • Rarely will a neurogenic bladder be accurately coded at G83.4.

Chapter 14: Diseases of the Genitourinary System—ScenarioA patient was admitted to home health for skilled nursing care following a successful kidney transplant. He still has stage 3b chronic kidney disease (CKD). Discharge encounter notes indicate that the patient also has early stage Parkinson's disease.

Code this scenario:

Chapter 14: Diseases of the Genitourinary System—Scenario

Aftercare following kidney transplant Z48.22

Chronic kidney disease, stage 3b N18.32

Parkinson's disease G20



Chapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Finds, Not Elsewhere Classified—Advanced Concepts

2021 Coding Updates• The Excludes1 note at R51, Headache for facial pain, migraine and trigeminal neuralgia has been

changed to an Excludes2 note.• Coders can now report both codes if appropriate.• R51 has been expanded to two new codes; R51.0, Headache with orthostatic component, NEC and

R51.9, Headache, unspecified.• R74.0, Nonspecific elevation of transaminase and LDH has been expanded to R74.01, Elevation of

levels of liver transaminase levels and R74.02, Elevation of levels of lactic acid dehydrogenase [LDH].• This change will assist in different clinical treatment modalities and resource utilization. For

example, an elevation in liver transaminases in a trauma patient could indicate the need for at CT scan looking for solid tissue injury; while an elevation in LDH could indicate a neoplastic condition.


• The FY2021 Official Guidelines for Coding and Reporting made a change that was not clearly evident in the updated guidelines.This was not evident in Coordination and Maintenance Committee meeting materials or made clear on the FY2021 OCG document. Below you will see that the lines for using the coma scale codes for “acute cerebrovascular disease or sequelae of cerebrovascular disease codes” and “The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.” have been removed for the Glasgow coma scale code guidelines regarding coma scale code assignment. This indicates that the Glasgow coma scale codes should be used in conjunction with traumatic brain injury codes only beginning with discharges October 1, 2020. AHA has stated the change was made to revert back to the original intent of the GCS codes, in that they originally were meant to be used for TBI cases only.

• The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition. The coma scale codes should be sequenced after the diagnosis code(s).

• These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.


SIRS due to non-infectious process• The systemic inflammatory response syndrome (SIRS) can develop as a result of certain non-infectious

disease processes, such as trauma, malignant neoplasm or pancreatitis. • When SIRS is documented with a noninfectious condition, and no subsequent infection is documented, the

code for the underlying condition, such as an injury, should be assigned followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction, or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.

• If an associated acute organ dysfunction is documented, the appropriate code(s) for the specific type of organ dysfunction(s) should be assigned in addition to code R65.11.

• If acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition (e.g., directly due to the trauma), the provider should be queried.



Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes—Advanced Concepts

Adverse Effects, Poisoning, Underdosing and Toxic Effects • Codes in categories T36-T65 are combination codes that include the substance that was taken as well as

the intent. • No additional external cause code is required for poisoning, toxic effects, adverse effects and

underdosing codes. • Do not code directly from the Table of Drugs and Chemicals. Always refer back to the Tabular List to

confirm the correct code. • Use as many codes as necessary to describe completely all drugs, medicinal or biological substances. • If the same code would describe the causative agent for more than one adverse reaction, poisoning,

toxic effect or underdosing, assign the code only once. • If two or more drugs, medicinal or biological substances are reported, code each individually unless a

combination code is listed in the Table of Drugs and Chemicals.


• Almost all amputations are the result of other medical conditions rather than accidents and are not coded with codes from Chapter 19 unless there are complications of the post-surgical amputation stump:• dehiscence (T87.81), • infection (T87.4-), • necrosis (T85.5-) or • neuroma (T87.3-).


Adverse Effect • When coding an adverse effect (hypersensitivity, reaction) of a drug that has been

correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50). • The code for the drug should have a 5th or 6th character “5” (e.g., T36.0X5-). • Examples of the nature of an adverse effect are tachycardia, delirium, gastrointestinal

hemorrhaging, vomiting, hypokalemia, hepatitis, renal failure or respiratory failure.




Poisoning • When coding a poisoning or reaction to the improper use of a medication (e.g., overdose,

wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36-T50, followed by additional code(s) for all manifestations of the poisoning. • The poisoning codes have an associated intent as their 5th or 6th character (accidental,

intentional self-harm, assault, and undetermined). • When no intent of poisoning is indicated, code to accidental.• Undetermined intent is only used when there is specific documentation in the record that

the intent of the poisoning cannot be determined.

Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes—Advanced Concepts• If there is also a diagnosis of abuse or dependence of the substance, the abuse or

dependence is assigned as an additional code. • Examples of poisoning include:

• Error was made in drug prescription or in the administration of the drug by provider, nurse, patient or other person.

• If an overdose of a drug was intentionally taken or administered and resulted in drug toxicity, it would be coded as a poisoning.

• Nonprescription drug or medicinal agent taken in combination with a correctly prescribed and properly administered drug, any drug toxicity or other reaction resulting from the interaction of the two drugs would be classified as a poisoning.

• When a reaction results from the interaction of drug(s) and alcohol, this would be classified as a poisoning.


Underdosing • Underdosing refers to taking less of a medication than is prescribed by the provider or as

instructed by the manufacturer whether inadvertently or deliberately. • For underdosing, a code from categories T36-T50 with a fifth or sixth character of “6” is used. • Use an additional code for underdosing intent such as patient’s non-compliance with medical

treatment and regimen (Z91.12-, Z91.13- or Z91.14) or failure in dosage during surgical and medical care (Y63.6-Y63.9). • Reminder, the physician needs to confirm this occurrence. • Codes for underdosing should never be assigned as principal or first-listed codes.• If a patient has a relapse or exacerbation of the medical condition for which the drug is

prescribed because of the reduction in dose, then the medical condition itself should be coded.




Toxic Effects • A toxic effect is classified when a harmful substance is ingested or comes in contact with a

person. • Codes for the toxic effect of substances that are chiefly nonmedicinal as a source (T51-T65)

include a 7th character to indicate the intention. • There are multiple notes at the top of this block of codes. • One states to use an additional code for all associated manifestations of toxic effect, such as

respiratory conditions due to external agents (J60- J70), personal history of foreign body fully removed (Z87.821) and to identify any retained foreign body, if applicable (Z18.-). • The second instructional note states: when no intent is indicated, code to accidental. • Undetermined intent is only for use when there is specific documentation in the record that the

intent of the toxic effect cannot be determined.


Transplant complications • Codes under category T86, Complications of transplanted organs and tissues, are used for both

complications and rejection of transplanted organs. • A transplant complication code is only assigned if the complication affects the function of the

transplanted organ. • Two codes are required to fully describe a transplant complication: the appropriate code from

category T86 and a secondary code that identifies the complication. • Pre-existing conditions or conditions that develop after the transplant are not coded as

complications unless they affect the function of the transplanted organs. • Patients who have undergone kidney transplant may still have some form of chronic kidney

disease (CKD) because the kidney transplant may not fully restore kidney function.


Transplant complications • A code from T86.1- should be assigned for documented complications of a kidney transplant,

such as a transplant failure or rejection or other transplant complication. • A code from T86.1- should not be assigned for post kidney transplant patients who have chronic

kidney disease (CKD) unless a transplant complication such as transplant failure or rejection is documented. • If the documentation is unclear as to whether the patient has a complication of the transplant,

query the provider. • Conditions that affect the function of the transplanted kidney, other than CKD, should be

assigned a code from T86.1-, Complications of kidney transplant, and a secondary code that identifies the complication. • For patients with CKD following a kidney transplant, but who do not have complications such as

failure or rejection, refer to codes in category N18 for CKD stages.




Codes for complications of surgical and medical care not elsewhere classified include• Complications following infusion, transfusion and therapeutic injection (e.g., T80.212-,

Local infection due to central venous catheter) • ABO, Rh and non-ABO incompatibility reactions due to transfusions of blood and blood

products. • Anaphylactic reaction due to serum, administration of blood and blood products, vaccine,

and other serum (T80.3-T80.89).


Complications of procedures, not elsewhere classified• Postprocedural shock (T81.1-T81.19); • Disruption of wound (T81.30-T81.33); • Infection following a procedure (T81.4-), with an additional code to identify infection and an

additional code from R65.2- to identify severe sepsis, if applicable; and • Complications of foreign body accidentally left in the body (T81.5-, T81.6-) • Complications of cardiac and vascular prosthetic devices, implants and grafts (T82.-) • Complications of genitourinary prosthetic devices, implants and grafts (T83.-), which includes

complications of urinary catheters, cystostomy catheters, other urinary devices and implants, and complications related to prosthetic devices, implants and grafts of the genitourinary tract.


Complications of procedures, not elsewhere classified• Complications of internal orthopedic prosthetic devices, implants and grafts. (T84.-). • Complications of other internal prosthetic devices, implants and grafts. (T85.-) • Complications of transplanted organs and tissues (T86.-). • Complications peculiar to reattachment and amputation (T87.-) • Other complications of surgical and medical care, not elsewhere classified (T88.-). • Complications involving stoma may be reported elsewhere. For example, a tracheostomy

complication is reported using a code from J95.0- in Chapter 10. A complication of an esophagostomy, colostomy or enterostomy is reported using a code from K94.- from Chapter 11




Complications of procedures, not elsewhere classified• Complications of internal orthopedic prosthetic devices, implants and grafts. (T84.-).• Complications of other internal prosthetic devices, implants and grafts. (T85.-) • Complications of transplanted organs and tissues (T86.-). • Complications peculiar to reattachment and amputation (T87.-) • Other complications of surgical and medical care, not elsewhere classified (T88.-). • Complications involving stoma may be reported elsewhere. For example, a tracheostomy

complication is reported using a code from J95.0- in Chapter 10. A complication of an esophagostomy, colostomy or enterostomy is reported using a code from K94.- from Chapter 11

Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes

Wounds • Many wounds in the Medicare home care population are the intentional result of medical

treatment. • Coding surgical wounds and medical amputations using Chapter 19 open wound codes is a

mistake because those codes are reserved for injuries (from accidents or violence). • Medically-caused wounds should not be coded from Chapter 19, unless they are complicated.

Even then, they should never be coded as open wounds. • If there is a complication of a surgery, a code from Chapter 19 will be used instead of the Z code

for aftercare. • The term “complication” should be referenced in the Volume 2 Alphabetic Index. Once the term

“complication” is found, reference the type of complication, such as infection or mechanical, to find the correct code.


Skin Tear• If the skin tear is complicated in some way – the tear no longer has a flap and is infected or

there is an underlying condition that is complicating the wound’s healing – then you may consider coding the skin tear as a laceration. • Coding the laceration as primary will place the claim into the wound grouper so ensure the skin

tear is really the focus of care, that skilled care is being provided, and that documentation supports the coding. • Most often the care of the skin tear is incidental to other skilled care and would be coded as a

secondary diagnosis. • Lacerations do not provide any comorbidity adjustment. Consult your specific MAC’s instructions

for coding skin tears that require skilled care.




Infection/complication coding • Occasionally, a post-surgical infection or other surgical complication code may be appropriate. • OASIS requires that home care clinicians use the WOCN guidelines to indicate the status of the

surgical wound. “Not healing” includes signs and symptoms of infection and delayed healing. • If there are signs and symptoms of infection, do not use the aftercare code for that surgery. The

aftercare code is indicated only for routine, uncomplicated care. • Subcategory T81.4- codes are commonly used for a post-surgical infection; however, some post-

operative infections have more specific codes, such as infected amputation, which is coded with T87.4-. Reference the Alphabetic Index to find the most specific code.


Infection/complication coding • The T81.4- subcategory allows coders to report the depth of the infection.• There are codes to specify whether the surgical wound infection is affecting the superficial incision

surgical site (T81.41-), the deep incisional surgical site (T81.42-) or the organ and space surgical site (T81.43-).

• Other surgical site and unspecified options are also available (T81.49- and T81.40-). • Each of these codes requires a seventh character: “A,” “D” or “S.” • Also, make note of the inclusion terms at each code, such as “subcutaneous abscess following a

procedure,” to help guide the appropriate code choice. • When a patient is admitted to home care primarily for surgical wound assessment and treatment, the

presence of a surgical drain is not a complication; it is a normal part of care for some surgical wounds. Care of surgical drains is included in the aftercare code for routine surgical care.

• If care includes removal or changing of the surgical drain, use Z48.03.


2021 Coding Updates• For S02.2 Contusion of thorax; S20.3 other superficial injuries of front wall of

thorax, new codes were added for “bilateral front wall of thorax” and “middle front wall of thorax”• All codes for T40.4X1-T40.4X6 for poisoning, adverse effect or underdosing of other

synthetic narcotics were deleted, adding it back later in T40.49-. • New codes for poisoning, adverse effect and underdosing of Tramadol, T40.42- and other

synthetic narcotics, T40.49- added.




• The port-a-cath or mediport site is considered a surgical wound as long as it is present, even if healed over. • Implanted infusion devices or venous access devices are considered surgical wounds, and it does not matter

whether the device is accessed with any particular frequency. • Only central venous catheters are considered surgical wounds. • Care of the uncomplicated venous or arterial line is coded Z45.2, Adjustment and management of a vascular

catheter. • Subsequent encounter to care for a bloodstream infection due to central venous catheter is coded T80.211D. • Local infection at the exit or insertion site due to central venous catheter is coded with T80.212D, but central line

associated infections (including PICC lines) are coded to T80.218D. • Extravasation or infiltration of a vesicant agent into surrounding tissue is a more serious complication of IV

therapy and is coded to T80.810 if related to the administration of vesicant antineoplastic chemotherapy or T80.818 if there is extravasation of another vesicant agent.

Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes—Scenario• A 57-year-old woman suffered a deep laceration to her right thigh when she accidentally

dropped a large kitchen knife. The wound was surgically repaired in the hospital, but later dehisced. She was admitted to home health for wound care, and also has diabetic peripheral neuropathy. She is insulin dependent.


Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes—ScenarioDisruption of traumatic injury wound repair, initial encounter

T81.33XA

Laceration without foreign body, right thigh, initial encounter

S71.111A


E11.42

Long term (current) use of insulin Z79.4

Contact with knife, initial encounter W26.0XXA



Chapter 20: External Causes of Morbidity—Advanced Concepts

2021 Coding Update• Added new external cause codes for injuries due to pedestrian conveyance accident,

standing electric scooter; and standing micro-mobility pedestrian conveyance (SEGWAY) (Hoverboard) vehicle.• They added contact lens and other ophthalmic devices associated with adverse incident

as new external cause codes Y77.11 and Y77.19

Chapter 21: Factors Influencing Health Status and Contact with Health Services—Advanced Concepts

2021 Official Guidelines for Coding and Reporting• Regarding documentation by clinicians other than the patient’s provider, the following

statement was added:• “Patient self-reported documentation may also be used to assign codes for social

determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.”

Chapter 22—Advanced Concepts

Poisoning and toxicity • Acute nicotine exposure can be toxic. • Children and adults have been poisoned by swallowing, breathing, or absorbing e-

cigarette liquid through their skin or eyes. • For these patients assign code:

• T65.291-, Toxic effect of other nicotine and tobacco, accidental (unintentional); includes Toxic effect of other tobacco and nicotine NOS.

• For a patient with acute tetrahydrocannabinol (THC) toxicity, assign code: T40.7X1- Poisoning by cannabis (derivatives), accidental (unintentional).



Patient Driven Groupings Model (PDGM)

Understanding PDGM basics

Payment will be based on the following 5 factors:

• Episode Timing--early or late• Admission Source—Community or Institutional• Clinical Grouping—12 subgroups determined by the primary diagnosis• Functional Level—3 groups– Low, Medium or High• Comorbidity Adjustment—None, Low or High determined by secondary diagnoses



PDGM Scoring

HIPPS Code

HIPPS Code



Finding a Diagnosis

No symptom codes

Is diagnosis accepted under PDGM?

Is diagnosis the focus of care for the episode?

May have to probe to find an alternate diagnosis

CMS Coding Expectations

What Do We Code?

• CMS expects that HHAs would report those diagnoses (both the principal diagnosis and secondary diagnoses) that reflect the primary reason for home health services and those that affect the home health plan of care. • This is in accordance with ICD-10-CM coding guidelines, which state:

• Select the principal diagnosis code that reflects the reason for the health care encounter• Report the additional diagnoses that affect patient care in terms of clinical evaluation, therapeutic

treatment, and increased nursing care or monitoring



What Do We Code?

• More specific and accurate diagnosis reporting to identify those conditions affecting the home health plan of care and to support the need for services is appropriate. • The home health Conditions of Participation (CoPs) at § 484.60(a), require that the home

health plan of care includes all pertinent diagnoses. • HHAs are required to consult the physician if there are any additions or modifications to

the plan of care. • Therefore, any diagnoses included on the home health plan of care would have to be

agreed upon by the physician responsible for the home health plan of care.

Goals of Accurate Coding

• Prevent RTP• Identify Comorbidities• Ensure accurate reimbursement

Current Issues

• Correct coding will result in episode payments that accurately reflect the severity of the patient’s condition and the level of skilled services required to meet the patient’s goals.

• Correct coding on first submission will reduce the number of claims returned to providers, which will save agencies and the Medicare Administrative Contractors (MACs) time and money and will result in better budget management for the entire program.

• CMS accurately captures population health data that will facilitate CMS making needed changes to PDGM over time based on patient characteristics, rather than nominal change



Tips for Sequencing

• What is the focus of care?• What other diagnoses may impact care, or be impacted by care, even if no active

treatment.• Prioritizing the care.• Only assessing clinician can determine primary and secondary diagnoses and the

symptom control rating.• Coder assigns the codes

Coding Clinic

• The AHA Central Office is the official U.S. Clearinghouse on medical coding for the proper use of the ICD-10-CM/PCS systems and Level I HCPCS (CPT-4 codes) for hospital providers and certain Level II HCPCS codes for hospitals, physicians and other health professionals who publishes the Coding Clinic quarterly and ensures published advice and guidance to ensure official answers are established for national consistency of the coded data.

Non-specific referrals

• What if the physician is in the process of determining a more definitive diagnosis?• CMS:

• With respect to patient safety and quality of care, we believe 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 regarding the gait abnormality.

• HHAs are required under the home health CoPs at § 484.60 to participate in care coordination to assure the identification of patient needs and factors that could affect patient safety and treatment efficacy.



Appropriate Primary Coding

• The majority of the R-codes (codes that describe signs and symptoms, as opposed to diagnoses) are not appropriate as principal diagnosis codes for grouping home health periods into clinical groups.• 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 as required at §484.60.• Clinically it is important for home health providers to have a clear understanding of the

patients’ diagnoses in order to safely and effectively furnish home health services.

Symptom Codes

We do not believe it appropriate to include the following as part of the clinical group case-mix variable because of the vague nature of symptom codes where there could be multiple reasons for such symptoms:

• R00.1 Bradycardia, • R41.82, Altered Mental Status, or • R42, Dizziness and giddiness

Dysphagia

• The following R-codes are a part of the Neuro Rehab clinical group: • R13.10, Dysphagia, unspecified • R13.11, Dysphagia, oral phase • R13.12, Dysphagia, oropharyngeal phase • R13.13 Dysphagia, pharyngeal phase • R13.14, Dysphagia, pharyngoesophageal phase • R13.19, Other dysphagia



R29.6 Repeated Falls

• ICD-10-CM coding guidelines state to only use R29.6 for use for encounters when a patient has recently fallen and the reason for the fall is being investigated. • Given that the patient must be certified for home health services and must have had a

face-to-face encounter related to the primary reason for home health services, CMS did not approve this code as appropriate for the principal diagnosis to substantiate home health services

Falls

• If the patient’s condition has resulted in repeated falls, the HHA would report Z91.81, History of falling, as a secondary diagnosis to describe that the patient has fallen in the past and is at future risk for falls to more accurately describe the patient’s need for home health services

Defining “other” Diagnosis

• The ICD-10-CM coding guidelines define “other” (additional) diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay”• The OASIS manual instructions state that “secondary diagnoses are comorbid conditions that

exist at the time of the assessment, that are actively addressed in the patient’s plan of care, or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis• The CoPs at § 484.60 state that the home health plan of care must include all “pertinent

diagnoses” and the accompanying interpretive guidelines state that this means that all “known diagnoses”



Clinical Grouping

Clinical Groupings and Coding

• Clinical Groupings were developed in large part to clearly identify the need for the home health episode, including the skilled services involved. • Allowing use of a vague code that does not clearly denote a treatment plan, would

invalidate the transparency we hope to achieve in the home health payment system.

Clinical Grouping

• PDGM requires each 30 day period to be categorized into one of 12 clinical groupings based on the principal diagnosis reported on the claim.• Groupings designed to capture the most common types of care provided by home health

agencies.• If a primary diagnosis code is used that does not fall into one of the clinical groupings,

then the claim will be returned to the provider



Clinical Groupings and Associated Reasons

Scenario Practice

Clinical grouping scenario

• Mr. Jones is a 68 year old male just discharged from rehab after hospitalization for Parkinson’s. His neurologist adjusted his Levodopa and has ordered SN and PT for assessment, medication compliance, and to help with gait issues related to his Parkinson’s. He also has physician confirmed Dementia, HTN, CKD, BPH, Urinary retention, and Dysphagia.

• Code this scenario

• What clinical grouping does the primary diagnosis fall in?



Clinical grouping

• NEURO/REHAB• G20 Parkinson's• F02.80 Dementia w/o behave disturbances in disease class elsewhere• I12.9 HTN CKD• N18.9 CKD• N40.1 BPH w/LUTS• R33.8 Other urinary retention• R13.10 Dysphagia

Clinical grouping scenario

• Ms. Smith was referred to home care after an acute hospital stay for UTI related to her Foley catheter. She then went to rehab for weakness related to Acute Kidney injury from the UTI. Both the UTI and AKI are resolved, but the physician has ordered monthly Foley changes. The patient also has Emphysema with Chronic Obstructive Bronchitis, DM controlled by oral hypoglycemics and uses supplemental oxygen at bedtime.

• Code this scenario

• What clinical grouping does the primary diagnosis fall in?

Clinical grouping

• COMPLEX NURSING INTERVENTION• Z46.6 Encounter for fitting and adjustment of urinary device• J44.9 Chronic obstructive pulmonary disease, unspecified• E11.9 Type 2 diabetes mellitus without complications• Z87.440 Personal history of urinary (tract) infections• Z99.81 Dependence on supplemental oxygen• Z79.84 Long term (current) use of oral hypoglycemic drugs



Comorbidity Adjustment


• Under PDGM, 30-day periods are categorized by a comorbidity adjustment based on the presence or lack of secondary diagnoses.

• The groupings are:• No comorbidity adjustment• Low comorbidity adjustment• High comorbidity adjustment


• Comorbidity adjustments are made for 30-day periods of care based on the following:• No comorbidity adjustment—No reported secondary diagnosis that falls in either the low

or high comorbidity adjustment.• Low comorbidity adjustment—There is a secondary diagnosis that is associated with

higher resource use.• High comorbidity adjustment—There are two or more secondary diagnoses that are

associated with higher resource use when both are reported together compared to being reported separately.




• A 30-day period cannot have both a low and high comorbidity at the same time. • If a 30-day period doesn’t have reported comorbidities that fit into one of the categories,

it would be assigned “no comorbidity adjustment.”

Low Comorbidity Adjustment

High Comorbidity Adjustment



High Comorbidity Adjustment

Clinical Grouping Example

• A 67 year old patient was referred to homecare after undergoing surgery for hernia repair. Due to intra-abdominal infection the wound was left partially open to allow for drainage and dressing changes to reduce risk of dehiscence. The patient also has chronic venous hypertension with inflammation and an ulcer noted to the left lower shin. Medical history also indicates mitral insufficiency and atrial fibrillation. The focus of care for this episode is on the post-surgical wound care. • Code this example:


• Z48.01-Encounter for change or removal of surgical wound dressing

• Z48.815-Encounter for surgical aftercare following surgery on the digestive system

• I87.332-Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity

• L97.829-Non-pressure chronic ulcer of other part of left lower leg with unspecified severity

• I05.1-Rheumatic mitral insufficiency

• I48.91-Unspecified atrial fibrillation




Clinical GroupingExample

• Should the aftercare code have been chosen as primary the Case-mix weight would have dropped to the following:

Comorbidity Example

• This 75 year old female was involved in a MVA and obtained a traumatic brain injury from which she is still recovering. PT was ordered for increase in strengthening due to the multiple injuries and extended hospital stay. Patient also has diagnoses of sprain of left medial collateral ligament of left knee and fracture of right and left shoulder. Other com-morbid diagnoses include DM, Hypothyroidism, mixed hyperlipidemia and bipolar disorder noted as currently in remission. • Code this example:



Comorbidity Example

• S06.2x9D-Diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter

• S83.412D-Sprain of medial collateral ligament of left knee, subsequent encounter• S42.101D-Fracture of unspecified part of scapula, right shoulder, subsequent encounter for fracture with

routine healing• S42.102D-Fracture of unspecified part of scapula, left shoulder, subsequent encounter for fracture with

routine healing• E11.9-Type 2 diabetes mellitus without complications• E03.9-Hypothyroidism, unspecified• E78.2-Mixed hyperlipidemia• F31.70-Bipolar disorder, currently in remission, most recent episode unspecified• V89.2XXD-Person injured in unspecified motor-vehicle accident, traffic, subsequent encounter

Comorbidity Example

Comorbidity Example

• The documentation does not reflect neuropathy, but should the patient have been diagnosed with neuropathy, E11.40 or E11.42 fall in the Neuro10 comorbidity group and would have increased the case mix to:



Comorbidity Example

• This 72 year old male is being admitted for observation and assessment/teaching and training regarding new medications for anemia. The anemia is the focus of care and was stated as not related to the CKD by the physician. The patient has been unstable due to fluctuation dizziness as a result of the anemia. His has had difficulty getting around and has a stage 2 pressure ulcer to the coccyx. SN and PT have been ordered. The patient also has ischemic cardiomyopathy, HTN, chronic combined systolic and diastolic heart failure, CKD stage IV, CAD, and paroxysmal atrial fibrillation. The SN will also oversee instruction regarding changing the continuous milrinone infusion. • Code this example:

Comorbidity Example

• D64.9-Anemia, unspecified• I25.5-Ischemic cardiomyopathy• I13.0-Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney

disease, or unspecified chronic kidney disease• I50.42-Chronic combined systolic (congestive) and diastolic (congestive) heart failure• N18.4-Chronic kidney disease, stage 4 (severe)• Z45.2-Encounter for adjustment and management of vascular access device• Z79.899-Other long term (current) drug therapy• L89.152-Pressure ulcer of sacral region, stage 2• I25.10-Atherosclerotic heart disease of native coronary artery without angina pectoris• I48.0-Paroxysmal atrial fibrillation

Comorbidity Example

• I13.0 falls into the Circulatory 4 comorbidity group• I50.42 falls into the Heart 11 comorbidity group• N18.4 falls into the Renal 1 comorbidity group• I25.10 falls into the Heart 12 comorbidity group• I48.0 falls into the Heart 10 comorbidity group• L89.152 falls into the Skin4 comorbidity group



Comorbidity Example

Comorbidity Example

Comorbidity Example



What If?• What would this scenario look like if the wound was not confirmed by the physician

and/or missed by the assessing clinician?

Comorbidity Example

• 68 year old male referred to home care for wound care after surgical amputation of left hand due to massive infection. Wound care is required to the amputation site. The patient has a history of HTN, DM, CKD stage 5, anemia and hyperlipidemia. • Code this scenario:

Comorbidity Example

• Z48.01-Encounter for change or removal of surgical wound dressing• Z47.81-Encounter for orthopedic aftercare following surgical amputation• Z89.112-Acquired absence of left hand• I12.0-Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end

stage renal disease• E11.22-Type 2 diabetes mellitus with diabetic chronic kidney disease• N18.5-Chronic kidney disease, stage 5• D63.1-Anemia in chronic kidney disease• E78.5-Hyperlipidemia, unspecified



Comorbidity Example

What if?• What if the coder did not recognize the need for wound care as primary and thought it

was just routine aftercare?

Coding Scenario

• 65 year old male referred to homecare after hospitalization for bleeding esophageal ulcer. Patient also has a diaphragmatic hernia, iron deficiency anemia, cardiomyopathy, HTN, chronic HFrEF, COPD, Emphysema, uncontrolled DM with blood sugars noted in the 300’s, Dementia and hyperlipidemia.• Code this scenario:



Coding Scenario

• K22.11-Ulcer of esophagus with bleeding• K44.9-Diaphragmatic hernia without obstruction or gangrene• D50.9-Iron deficiency anemia, unspecified• I42.9-Cardiomyopathy, unspecified• I11.0-Hypertensive heart disease with heart failure• I50.22-Chronic systolic (congestive) heart failure• J43.9-Emphysema, unspecified• E11.65-Type 2 diabetes mellitus with hyperglycemia• F03.90-Unspecified dementia without behavioral disturbance• E78.5-Hyperlipidemia, unspecified

M1033 Considerations

M1033 Considerations

• Base rate of $1864.03 x 1.1867= $2212.04 without adjustments for 30 day billing period.

• Base rate of $1864.03 x 1.3415= $2500.59 without adjustments for 30 day billing period for a loss of $288.55 by one click on M1033 in the OASIS assessment



15 Minute Break

Success Tips for PDGM



Focus of Care Meetings

• Has your team established a process for identifying potential diagnosis/focus of care changes for the 2nd 30 period in the billing cycle?• Consider a 3 week Team/Individual Focus of Care Case Conference Meeting with the

clinician and Team Leader to review and plan for the next billing period…focus of care, outstanding orders.• Consider allowing QA/Marketing Personnel to attend these meetings

Quality Review Process

• Primary and co-morbidity codes reviewed and validated.• Consider use of outsourced coding or internal coding audits as a part of your QA process• Do the primary and co-morbid diagnoses relate to the plan of care and support the need

for home health services.• Are these diagnoses pulling to the claim correctly?

Remember: Unacceptable Primary Diagnoses (May still be used as secondary)• C34.90 Malignant neoplasm of unspecified part of unsp bronchus or lung• E11.8 Type 2 diabetes mellitus with unspecified complications• M06.9 Rheumatoid arthritis, unspecified• M19.90 Unspecified osteoarthritis, unspecified site• M54.5 Low Back Pain• M62.81 Muscle Weakness (generalized)• M62.838 Other muscle spasm• Z51.89 Encounter for other specified aftercare• Z91.81 History of falling• No R codes except R13.1-- (Dysphagia codes)



You treat a disease, you win, you lose. You treat a person, I guarantee you,

you'll win, no matter what the outcome

Questions?

NANETTE MINTONMAC LegacySenior Clinical Coding Manager, RN, CHPCA, HCS-D, [email protected]

References• https://www.govinfo.gov/content/pkg/FR-2020-11-04/pdf/2020-24146.pdf• Decision Health Complete Home Health and Hospice ICD-10-CM Diagnosis Coding Manual

2021• https://www.healthpro-heritage.com/blog/coding-for-success-in-pdgm• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HomeHealthPPS/HH-PDGM• https://codingcenter.decisionhealth.com/MVC/Scenarios/ICD10/298#!#scenario-

6135684• https://www.hiacode.com/education/new-icd-codes-and-ipps-changes-part-

1/#:~:text=If%20the%20patient%20is%20treated,(current)%20drug%20therapy.%E2%80%9D



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Documents

MAC Legacy Advanced Coding through the PDGM Looking …...coding principles as they relate to PDGM in Home Care. Learning Objectives • Enhance the knowledge of the learner on the