Trauma codes misused by home health agencies
Relevant medical diagnosis should be reported
A number of home health agencies are incorrectly using the diagnosis codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) when reporting the primary diagnosis for post-surgical admissions on the Outcome and Assessment Information Set (OASIS) and Uniform Billing Form-92 (UB-92), reports the Health Care Financing Administration (HCFA) in Baltimore. The agencies 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 surgeries and amputations performed for treating disease are not coded from the "Injury and Poisoning" section.
The only common condition in home health in which a trauma code is used is fracture due to a fall, other accident, or intentional injury, HCFA says. 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. HCFA says this requirement raises a problem for diagnosis coding in many post-surgical wound care cases.
How to code wound care diagnosis?
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, 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 is considered cured after surgery.
Agencies that have erroneously coded disease-related post-surgical cases with a trauma diagnosis should submit a corrected claim to ensure accurate payment.
Also, HCFA says to note the following guidance issued in Program Memorandum (PM) A-00-71 (www.hcfa.gov/pubforms/transmit/a0071.pdf). This PM stipulates that "the principal diagnosis must match on the physician-certified plan of care, the OASIS and the 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.
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