OASIS Implementation Manual
Chapter 8, Attachment D
1. GENERAL DIAGNOSIS CODING PRINCIPLES AND CODING ISSUES SPECIFIC TO M0230
The logic for determining the primary (first listed) diagnosis for M0230 remains unchanged under the Medicare fee-for-service home health prospective payment system (PPS). Determine the primary diagnosis based on the condition most related to the current plan of care. The diagnosis may or may not be related to a patient's recent hospital stay but must relate to the services rendered by the HHA. Skilled services (skilled nursing, physical, occupational, and speech therapy) are used in judging the relevancy of a diagnosis to the plan of care and to OASIS item M0230.
If a patient is admitted for surgical aftercare, list the relevant medical diagnosis only if it is still applicable. If it is no longer applicable (e.g., the surgery eliminated the disease or the acute phase has ended), then a V code, such as for surgical aftercare, is generally appropriate as the primary diagnosis. The importance of this principle can be seen in the example of hospitalization for the surgical repair of a hip fracture. Coding guidelines stipulate that the acute fracture code may only be used for the initial, acute episode of care, which is why the acute fracture code is no longer appropriate once the patient has been discharged from the hospital to home health care.
V codes cannot be used in case mix group assignment. Effective October 1, 2003, if a provider reports a V code in M0230 in place of a case mix diagnosis, the provider has the option of reporting the case mix diagnosis in M0245. You must select the code(s) that would have been reported as the primary diagnosis under the original OASIS-B1 (8/2000) instructions that did not allow V codes. The CMS web site contains additional guidelines for diagnosis reporting under PPS at: http://www.cms.hhs.gov/providers/hhapps/hhdiag.pdf.
2. MANIFESTATION CODES
In certain cases, ICD-9-CM requires more than one code to report a condition. This requirement, termed "multiple coding of diagnoses," often involves both a disease and one of its manifestations. The ICD-9-CM manual clearly shows the instances where manifestation coding is required.
- Manifestation coding affected some of the PPS case mix system's diagnosis groups.
- The PPS Final Rule listed certain manifestation codes carrying points under the case mix system. See the PPS Final Rule published July 3, 2000 on the CMS Web site at: http://www.cms.hhs.gov/providers/hhapps/hhppsfr.asp
- The manifestation codes must appear with all required digits in their proper sequence as the first secondary diagnosis.
- Do not report any code except the underlying cause of the manifestation in the position immediately preceding the manifestation code.
- Effective October 1, 2003, a V code may be determined to be the primary diagnosis in place of a disease and one of its manifestations. In that case, a single V code is listed as the primary diagnosis instead of the first two listed codes. However, the underlying condition may still be listed as a secondary diagnosis, if it meets the requirements for a secondary diagnosis.
3. GENERAL DIAGNOSIS CODING PRINCIPLES AND CODING ISSUES SPECIFIC TO M0240
- Secondary diagnoses are defined as "all conditions that coexisted at the time the plan of care was established, or which developed subsequently, or affect the treatment or care."
4. V CODE GENERAL PRINCIPLES
- The use of V codes is governed by the ICD-9-CM Official Guidelines for Coding and Reporting.
- If the patient has an acute condition relevant to the plan of care, continue to report the code for the acute condition. Whether it is listed as a primary or secondary diagnosis depends on the focus of care indicated on the plan of care. V codes are intended to deal with circumstances other than the diseases or injuries classifiable to the main part of ICD-9-CM (codes 001-999). For example, V codes are recorded as reasons for encounters with a health care provider.
- V codes may be used as the primary or secondary diagnoses.
- The major use of V codes in the home health setting occurs when a person with current or resolving disease or injury encounters the health care system for specific aftercare of that disease or injury.
- If there is a complication of medical or surgical care, such as infection or wound dehiscence, select a code specific to either condition rather than V code. For example, codes for surgical complications are available within Chapter 17 of the ICD-9-CM coding guidelines and elsewhere.
- E codes classify external causes of injuries, poisonings, and adverse effects of drugs.
- E codes are used in addition to a code from one of the main chapters of ICD-9-CM and are never to be recorded as a primary diagnosis.
- E codes may not be entered in M0230(a) or M0245.
- If an E code is reported, do not rate its severity.
6. GENERAL DIAGNOSIS CODING PRINCIPLES AND CODING ISSUES SPECIFIC TO M0245
M0245 Payment Diagnosis code is an optional OASIS item that home health agencies may use if a V code is selected in M0230 according to ICD-9-CM coding guidelines. M0245 is intended to facilitate PPS payment operations after October 2003 when a V code may be required as the primary diagnosis in place of certain diagnosis codes used to determine the PPS case mix group. This item will be inactive to prevent use until October 2003 and is shaded on the OASIS 12/2002 data set. Therefore, HHAs will not be able to enter this item in HAVEN or to transmit the data until the item is activated in October 2003. Once M0245 is operational, HHAs may enter a case mix diagnosis code at their option, only if they have entered a V code in place of a case mix diagnosis code in M0230.
a) Complete M0245 if a V code has been reported in place of a home health PPS case mix diagnosis in M0230. To complete M0245, you must select the code(s) that would have been reported as the primary diagnosis under the OASIS-B1 (8/200) instructions:
• No surgical codes - list the underlying diagnosis.
• No V codes or E codes - list the relevant medical diagnosis.
• If the patient's primary home care diagnosis is coded as a combination of
an etiology and a manifestation code, the etiology code should be entered in M0245(a) and the manifestation code should be entered in M0245(b).
b) Do not complete M0245 if a V code has been reported in place of a
diagnosis that is not a case mix diagnosis.