icd-9-cm home health coding impact on · pdf file5/12/2010 1 icd-9-cm home health coding...

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ICD-9-CM Home Health Coding Impact on Reimbursement

Presented by HealthCare ConsultLink

Linda Parker, RN, BSN, COS-C, HCS-D

Objectives

Identify principles for determining primary/secondary diagnoses

Identify when to complete M1024

List 3 possible negative impacts of coding on reimbursement

Source Documents …

CMS OASIS-C Guidance Manual Chapter 3 pages C-8 through C-11

ICD-9-CM Official Guidelines for Coding and Reporting

www.ahacentraloffice.org/ahacentraloffice/html/links.html

Home Health Prospective Payment System regulations

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CMS definition

The principal diagnosis is the diagnosis most related to the current plan of treatment.

It may or may not be related to the patient’s most

DETERMINING PRIMARY DIAGNOSIS: The logic for determining the primary (first listed) diagnosis remains unchanged.

It may or may not be related to the patient s most recent hospital stay, but must relate to the services the home health agency rendered.

If more than one diagnosis is treated concurrently, enter the diagnosis that represents the most acute condition and requires the most intensive services.

Skilled services (SN, PT, OT and SP) only.

The assessing clinician has to determine the primary and secondary diagnoses and symptom control rating, after

completing the OASIS Assessment

DETERMINING PRIMARY DIAGNOSIS:

Why am I seeing this patient?

What is the primary focus of skilled services?

Are there co-morbidities that may impact the POC?

Do not consider the number of visits per discipline as a basis for your decision!

INCLUDE those conditions actively addressed as well as any co-morbidities affecting the patient’s response to treatment

Determining Primary/Secondary Diagnoses:

EXCLUDE diagnoses that no longer pertain to the plan of care, i.e., hip fracture, appendicitis, gangrene, etc.

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Co-Morbidity Information:

There are some co-morbidities that should always be coded because they are impacted or they may impact the care.

CMS states that any co-morbidity affecting the patient’s responsiveness to treatment and rehabilitative prognosis, even if the condition is not the focus of any home health treatment itself, should be listed.

Diabetes COPD

HTN CHF

CAD Status amputation

ALWAYS CODE THESE CO-MORBIDITIES

C S a us a pu a o

PVD Blindness

Chronic diseases, such as Parkinson’s

History of malignant neoplasm when care is directed at a current neoplasm or otherwise impacts the care

Co-Morbidity Information

Plan of Care should reflect all diagnoses including co-morbidities#21 SN to assess diabetes and HTN for potential impact on

plan of care

#22 Patient will have no complications related to diabetes#22 Patient will have no complications related to diabetes and HTN this episode

If therapy only, co-morbidities must also be addressed in therapy Plan of CarePT to check blood pressure every visit and report to physician

if >185/95 and/or < 90/60

Patient’s blood pressure will remain within parameters this episode

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DO NOT automatically code something without physician

d t ti i ti

Primary/Secondary Diagnoses

documentation or communication with the physician documented, i.e.,

urinary retention or neurogenic bladder

A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and

Guidance from Official Coding Guidelines

g p g gprocedures.

In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.

§484.18(a) Standard: Plan of Care

“If a physician refers a patient under a plan of care that cannot be completed

Guidance from Medicare CoP

until after an evaluation visit, the physician is consulted to approve additions or modification to the original plan.”

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Agencies should avoid listing diagnoses that are of mere historical

Guidance from OASIS Manual

interest and without impact on the patient progress or outcome.

(OASIS-C Guidance Manual Chapter 3 Item Intent C-9)

Coding Impact on Reimbursement

Payment based on an HHRG (Home Health Resource Group)

OASIS items M0110 and M2200 determine payment equationp y q

20 additional OASIS items determine Clinical severity score

Functional severity score

Service Utilization severity score

ICD-9-CM codes are part of the clinical severity score

Coding Impact on Reimbursement Clinical Domain – 22 Diagnostic Categories

1 - Blindness & Low Vision 12 - Neuro 3 (Stroke)2 - Blood Disorders 13 - Neuro 4 (MS)3 - Cancers & Neoplasms 14 - Ortho 1 (Leg)4 - Diabetes 15 - Ortho 2 (Other)5 - Dysphagia 16 - Psych 1 (Affective)5 - Dysphagia 16 - Psych 1 (Affective)6 - Gait Abnormality 17 - Psych 2 (Degenerative)7 - Gastrointestinal Disorder 18 - Pulmonary8 - Heart Disease 19 - Skin 1 (Trauma & Burns)

9 - Hypertension 20 - Skin 2 (Ulcers & Other)10 - Neuro 1 (Brain) 21 - Tracheostomy Care11 - Neuro 2 (Peripheral) 22 - Urostomy/Cystostomy

Care

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See Handout # 1

T bl 5


Table 5

Case-Mix Adjustment Variables and Scores


Potential points for M1020a and M1022b-f

Potential points for combined diagnoses – See Variable 6

Potential points for combination with M00 item – See Variable 7

Out of 22 diagnostic categories only 3 with potential for UPCODING –

Diabetes – Diagnostic Group 4

Neuro 1 – Diagnostic Group 10

Skin 1 – Diagnostic Group 19

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See Handout # 2

Table 6

Coding Impact on NRS

Table 6

Non-Routine Supply

Case-Mix Adjustment

Variables and Scores

Other ICD-9-CM Coding impacts on reimbursement -

Codes must match on the OASIS, POC (485), and the bill (UB04)

OASIS M1020 and M1022 has 6 spaces for codes

POC (485) has unlimited spacesUB04 Claim form has 9 spaces + E

Code

Not following rules for sequencing manifestations

h h

Other ICD-9-CM Coding impacts on reimbursement -

Leaving off a required 4th or 5th

digit of the code

Not completing M1024

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See Handout # 3

Completing M1024

OASIS-C

M1020, M1022, M1024

(M1020) Primary Diagnosis & (M1022) Other Diagnosis

(M1024) Payment Diagnoses (OPTIONAL)

Column 1 Column 2 Column 3 Column 4

Diagnoses(Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided)

ICD-9-C M and symptom control rating for each condition.Note that the sequencing of these ratings may not match the sequencing of the diagnoses

Complete if a V-code is assigned under certain circumstances to Column 2 in place of a case mix diagnosis.

Complete only if the V-code in Column 2 is reported in place of a case mix diagnosis that is a multiple coding situation (e.g., a manifestation code).

Description ICD-9-C M /Symptom Control

Rating

Description/ICD-9-C M


(M1020) Primary Diagnosisa.

(V-codes are allowed)a. (__ __ __ - __ __)

☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4

(V- or E-codes NOT allowed)a. (__ __ __ - __ __)

(V- or E-codes NOT allowed)a. (__ __ __ - __ __)

(M1022) Other Diagnosesb.

(V- or E-codes are allowed)

b. (__ __ __ - __ __)☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4

(V- or E-codes NOT allowed)b. (__ __ __ - __ __)

(V- or E-codes NOT allowed)b. (__ __ __ - __ __)

Completing M1024

M1024 is a Case Mix MONEY item

Per CMS, M1024 is optional – you don’t have to p yclaim payment

Grouper programmed to go to M1024 if a V code is in M1020 or M1022

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M1024 facts

M1024 does not automatically go to the UB04 or 485 as it for HHRG calculation only

Diagnosis must be in M1020 or M1022 to appear on 485 or UB04on 485 or UB04

Guidance from CMS – the diagnosis in M1024 must appear on the 485 either in items 11, 13 or 21

So must ASK …

M1024 facts

Does the condition still exist?

If no, then list in M1024 and include on 485 #21 but DO NOT list in M1022

If yes, then no need to list in M1024 per Attachment D guidelines as will be in M1022 as condition still exists

When to complete M1024

Skip M1024 if –

No V code in Column 2 for M1020 or M1022

V code in Column 2 M1020 or M1022 and DOES NOT replace a Case Mix Diagnosis

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When to complete M1024

Complete M1024 if – V code in M1020 or M1022 and it replaces a

Case Mix Diagnosis

Th t i t l d That is not resolved or

Gives more points –

Diabetes,

Skin 1 or

Neuro 1

M1020 Primary & M1022 Other Diagnoses M1024Case Mix Diagnoses (OPTIONAL)

(1) (2) (3) (4)

a. After following joint replacement

a. V54.81 a. Fx hip

820

a.

Aftercare following right hip joint replacement due to traumatic fracture. SN for PT/INR, Stage 1 pressure ulcer left hip and PT for gait abnormality.

b. Pressure ulcer left hip b. 707.04 b. b.

c. Stage 1 pressure ulcer c. 707.21 c. c.

d. Joint, hip d. V43.64 d. d.

e. Encounter for therapeutic drug monitoring

e. V58.83 e. e.

f. Anticoagulant f. V58.61

M1020 Primary & M1022 Other Diagnoses M1024Case Mix Diagnoses (OPTIONAL)

(1) (2) (3) (4)

a. Other aftercare following specified surgery

a. V58.49 a. Diabetes

250.70

a. Gangrene

785.4

b Di b t ith i h l b 250 70 b b

Aftercare following BKA due to gangrene in a diabetic patient with PVD. SN for dressing change, diabetic teaching and PT for gait abnormality.

b. Diabetes with peripheral manifest

b. 250.70 b. b.

c. PVD c. 443.81 c. c.

d. Lower limb amputation status

d. V49.75 d. d.

e. Dressing change e. V58.31 e. e.

f. f. f. f.

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M1020 Primary & M1022 Other Diagnoses M1024 Case Mix Diagnoses (OPTIONAL)

(1) (2) (3) (4)

a. PT a. V57.1 a. a.

b R it ’ Di b 099 3 b b

PT to eval and treat arthropathy of the lower leg due to Reiter’s Disease.

b. Reiter’s Disease b. 099.3 b. b.

c. Arthropathy c. 711.16 c. c.

d. d. d. d.

e. e. e. e.

f. f. f. f.

Specific Diagnostic Category Considerations

Diabetes –

250 Category

(Variables 4 & 5)

250.xx requires both a 4th and 5th digit

4th digit = without or with complication

5th digit = type and if controlled or not

CODING DIABETES

5th digit = type and if controlled or not

Usually requires 2 codes

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250.4x with renal manifestation

250.5x with opthalmic manifestation

Coding Diabetes – Subcategory (4th digit) Requiring a Manifestation Code

250.6x with neurological manifestation

250.7x with peripheral circulatory disorders

250.8x with other specified manifestations

250.9x unspecified complication – DO NOT USE

Diabetes/macular edema requires 3 codes:

250.5x 362.07 362.0x

Diabetic Coding Tips:

Diabetes/acute osteomyelitis requires 3 codes:

250.8x 731.8 730.0x

• Use V58.67 with Type 2 diabetics on insulin to paint better picture

Diabetic Coding Tips:

• Do not use V58.67 with Type I diabetics as redundant

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(1) (2) (3) (4)

a. Diabetes, type 2 with neuro manifestation

a. 250.6 a. a.

A patient is admitted to home care with uncontrolled, Type 2 diabetes. The insulin regime has been modified and the patient is to be monitored for overall condition. Patient also has diagnosis of diabetic polyneuropathy.

b. Polyneuropathy b. 357.2 b. b.

Would Agency get the primary Diabetes points?


(1) (2) (3) (4)

a. Diabetes, type 2 with neuro manifestation

a. 250.62 a. a.

A patient is admitted to home care with uncontrolled, Type 2 diabetes. The insulin regime has been modified and the patient is to be monitored for overall condition. Patient also has diagnosis of diabetic polyneuropathy.

b. b. b. b.

Would Agency get the primary Diabetes points?

These codes are used to show type of visual impairment “due to” a condition, e.g., glaucoma, cataracts, etc.

Not used for refractive errors

Specific Diagnostic Category Considerations – Blindness

369.x codes are NOT used just because they are old – that would be UPCODING!

Legal Blindness in the United States is coded differently from WHO definition - choose your codes carefully

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Specific Diagnostic Category Considerations

Neuro 3 – Stroke, to include:

• Hemiplegia and HemiparesisM l i• Monoplegia

• Cauda Equina Syndrome• Late Effects CVA• Neuro Neglect Syndrome

(Variables 10, 15, 16, 17)

Late effects of CVA may require –Only a 4th digitA 5th digit

Specific Diagnostic Category Considerations - CVA

4th digit and an additional code5th digit and an additional code

Muscle weakness, seizures or contractures as late effect of CVA are coded with 438.89

M1020 Primary & M1022 Other Diagnoses

M1024 Case Mix Diagnoses (Optional)

(1) (2) (3) (4)

a. Late effects of CVA w/Hemiplegia

a. 438.21 a. a.

Patient referred to home care following an acute CVA with flaccid hemiplegia affecting dominant side and dysphagia requiring enteralfeeding (M1030 Therapy in home = 3). SN, PT, OT and ST ordered. OASIS-C scores dressing lower body as 2 and ambulation as 4.

b. Late effects of CVA w/dysphagia

b. 438.82 b. b.

c. Dysphagia, unspecified

c. 787.20 c. c.

How many Clinical points if Early episode and 20 therapy visits?

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M1020 Primary & M1022 Other Diagnoses M1024 Case Mix Diagnoses (Optional)

(1) (2) (3) (4)

a. Fitting and adjustment of urinary catheter

a. V53.6 a. a.

b U i i ti b 788 30 b b

MS patient requires monthly foley catheter change by SN. No recent exacerbations of MS. Physician has verified urinary incontinence as reason for catheterization.

b. Urinary incontinence b. 788.30 b. b.

c. MS c. 340 c. c.

Would Agency get the MS points?

How many NRS points?

Specific Diagnostic Category Considerations – Ortho

Note that many Ortho 1 and Ortho 2 codes are

Manifestation Codes and must be partnered with the

underlying cause to qualify for points

Specific Diagnostic Category Considerations – V Codes

V55.0 – Tracheostomy Care(Variable 29)

V55.5 – Cystostomy CareV55.6 – Other artificial Opening of

Urinary Tract – Nephrostomy, Ureterostomy, Urethrostomy

(Variable 30)

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SCENARIOS…

Scenario 1

REFERRAL INFORMATION:

Left hip fracture and Stage 1 pressure ulcer on coccyx

Physical therapy 3 times a week for gait and balancePhysical therapy 3 times a week for gait and balance training

DATA OBTAINED THROUGH ASSESSMENT:

Minoxidil found in home

Amputation of third and fourth toes, right foot 10 years ago due to trauma injury

List diagnoses that you can code at this point:

List diagnoses that physician must confirm:

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Sequence other diagnoses for home care that would go in M1022:

What is the primary reason for home care in M1020?

Any codes in M1024?

Scenario 2


Fall at home resulting in 2 skin tears (category 3) to right forearm and one skin tear (category 2) to right elbow. Daily dressing change. Uncontrolled type 1 diabetes Muscle weakness requiring physicaldiabetes. Muscle weakness requiring physical therapy.


Patient states legally blind and has tingling in feet

Lexapro found in home and patient exhibiting S/S depression



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Any codes in M1024?

Scenario 3


Hypertensive heart disease; uncontrolled blood pressure; Atrial fib and on Coumadin

SN to monitor BP daily for 2 weeks; obtain PT/INR on d it d kl f 2 kadmit and weekly for 2 weeks

CABG 6 months ago following MI


Patient states physician told him he had heart failure

New RX Nexium found in home and patient c/o heart burn



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Any codes in M1024?

Scenario 4


Primary focus of care is aftercare following surgery for malignant melanoma of skin on upper arm. Cancer completely removed and no further p ytreatment ordered. Dressing change ordered.


Patient unable to administer Vit B12 injections due to surgery and no available caregiver



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Any codes in M1024?

Scenario 5


Acute exacerbation of COPD with asthma requiring oxygen

Muscle weakness due to CVA 8 months ago requiringMuscle weakness due to CVA 8 months ago requiring PT

History of HTN


Oxygen delivered yesterday and patient concerned about use

Refuses PT until dyspnea improves



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DETERMINE TOTAL POINTS per Equation

M1020 Primary & M1022 Other Diagnoses Points per Equations

Diagnosis Code (1) (2) (3) (4)

Chr obstr asthmaIf Ambulation = 1 or more

493.22

Late effect CVAIf Drsg upper or lower body

= 1, 2, or 3

438.89

If Ambulation = 3 or more

Muscle weakness 728.87

HTN 401.9

Oxygen V46.2

TOTAL Possible Points

IN SUMMARY…

M1024 not completed when a V code replaces a case mix diagnosis in M1020

or M1022

Negative impacts of coding on reimbursement…..

Diagnosis does not include all required digits

Required manifestation code not listed

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Manifestation code sequenced above etiology

Not all co-morbidities are listed, i.e. blindness, hypertension, CHF, COPD, history of neoplasm


Not all diagnoses are listed, i.e., pressure ulcer (stage 1), depression

Sequencing of diagnoses not supported by documentation

UPCODING Diabetes, Skin 1 & Neuro 1 Categories

To Rise to the Challenge and Thrive …..

Utilize current ICD-9-CM Coding Manuals

Be aware of annual changes to codesg

Ensure staff receive basic coding and OASIS education on hire and at least annually

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To Rise to the Challenge and Thrive …..

DO NOT give in to….

300.01 Panic attack

780.95 Excessive crying of the adult

780.52 Insomnia, unspecified

531.9 Gastric ulcer

995.82 Adult emotional/psychological abuse

Table 5 (formerly Table 2A)

Episode number within sequence of adjacent episodes 1 or 2 1 or 2 3+ 3+

Therapy visits 0-13 14+ 0-13 14+

EQUATION: 1 2 3 4

1 Primary or Other Diagnosis = Blindness/Low Vision 3 3 3 3

2 Primary or Other Diagnosis = Blood disorders 2 5

3 Primary or Other Diagnosis = Cancer, selected benign neoplasms

4 7 3 10

4 Primary Diagnosis = Diabetes 5 12 1 8

5 Other Diagnosis = Diabetes 2 4 1 4

Primary or Other Diagnosis = Dysphagia 2AND Primary or Other Diagnosis = Neuro 3 - Stroke

Primary or Other Diagnosis = Dysphagia ANDM0250 (Therapy at home) = 3 (Enteral)

8 Primary or Other Diagnosis = Gastrointestinal disorders 2 6 1 4

Primary or Other Diagnosis = Gastrointestinal disorders 3AND M0550 (ostomy)= 1 or 2

Primary or Other Diagnosis = Gastrointestinal disorders AND Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis, OR Neuro 2 - Peripheral neurological disorders, OR Neuro 3 - Stroke, OR Neuro 4 - Multiple Sclerosis

11 Primary or Other Diagnosis = Heart Disease OR Hypertension 3 7 1 8

12 Primary Diagnosis = Neuro 1 - Brain disorders and paralysis 3 8 5 8

Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis

3

AND M0680 (Toileting) = 2 or more

Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis OR Neuro 2 - Peripheral neurological disorders

2

AND M0650 or M0660 (Dressing upper or lower body)= 1, 2, or 3

15 Primary or Other Diagnosis = Neuro 3 - Stroke 1

Primary or Other Diagnosis = Neuro 3 - Stroke 1AND M0650 or M0660 (Dressing upper or lower body)= 1, 2, or 3

2 214 4

3 2 816

210

3 1013 10

7 6

9

CLINICAL DIMENSION

66 6

ICD-9-CM Coding and Reimbursement Hand Out # 1




EQUATION: 1 2 3 4

Primary or Other Diagnosis = Neuro 3 - Stroke 1ANDM0700 (Ambulation) = 3 or morePrimary or Other Diagnosis = Neuro 4 - Multiple Sclerosis AND AT LEAST ONE OF THE FOLLOWING:

3

M0670 (bathing) = 2 or more OR M0680 (Toileting) = 2 or moreOR M0690 (Transferring) = 2 or more OR M0700 (Ambulation) = 3 or morePrimary or Other Diagnosis = Ortho 1 - Leg Disorders or Gait Disorders

2

AND M0460 (most problematic pressure ulcer stage)= 1, 2, 3 or 4Primary or Other Diagnosis = Ortho 1 - Leg OR Ortho 2 - Other orthopedic disorders

5

AND M0250 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral)

21 Primary or Other Diagnosis = Psych 1 – Affective and other psychoses, depression

3 5 2 5

22 Primary or Other Diagnosis = Psych 2 - Degenerative and other organic psychiatric disorders

1 2 2

23 Primary or Other Diagnosis = Pulmonary disorders 1 5 1 5

Primary or Other Diagnosis = Pulmonary disorders 1ANDM0700 (Ambulation) = 1 or more

25 Primary Diagnosis = Skin 1 -Traumatic wounds, burns, and post-operative complications

10 20 8 20

26 Other Diagnosis = Skin 1 - Traumatic wounds, burns, post-operative complications

6 6 4 4

Primary or Other Diagnosis = Skin 1 -Traumatic wounds, burns, and post-operative complications OR Skin 2 – Ulcers and other skin conditions

2

AND M0250 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral)

28 Primary or Other Diagnosis = Skin 2 - Ulcers and other skin conditions

6 12 5 12

29 Primary or Other Diagnosis = Tracheostomy 4 4 4

30 Primary or Other Diagnosis = Urostomy/Cystostomy 6 23 4 23

24

227

19

20 5

17 5

12 1818 3





EQUATION: 1 2 3 4

31 M0250 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral) 8 15 5 12

32 M0250 (Therapy at home) = 3 (Enteral) 4 12 12

33 M0390 (Vision) = 1 or more 1 1

34 M0420 (Pain)= 2 or 3 1

35 M0450 = Two or more pressure ulcers at stage 3 or 4 3 3 5 5

36 M0460 (Most problematic pressure ulcer stage)= 1 or 2 5 11 5 11

37 M0460 (Most problematic pressure ulcer stage)= 3 or 4 16 26 12 23

38 M0476 (Stasis ulcer status)= 2 8 8 8 8

39 M0476 (Stasis ulcer status)= 3 11 11 11 11

40 M0488 (Surgical wound status)= 2 2 3

41 M0488 (Surgical wound status)= 3 4 4 4 4

42 M0490 (Dyspnea) = 2, 3, or 4 2 2

43 M0540 (Bowel Incontinence) = 2 to 5 1 2 1

44 M0550 (Ostomy)= 1 or 2 5 9 3 9

45 M0800 (Injectable Drug Use) = 0, 1, or 2 1 1 2 4

46 M0650 or M0660 (Dressing upper or lower body)= 1, 2, or 3 2 4 2 2

47 M0670 (Bathing) = 2 or more 3 3 6 6

48 M0680 (Toileting) = 2 or more 2 3 2

49 M0690 (Transferring) = 2 or more 2

50 M0700 (Ambulation) = 1 or 2 1 1

51 M0700 (Ambulation) = 3 or more 3 4 4 5

Points are additive, however points may not be given for the same line item in the table more than once.

Notes: The data for the regression equations come from a 20 percent random sample of episodes from CY 2005. The sample excludes LUPA episodes, outlier episodes, and episodes with SCIC or PEP adjustments.

Please see Medicare Home Health Diagnosis Coding guidance at http://www.cms.hhs.gov/HomeHealthPPS/03_coding&billing.asp for definitions of primary and secondary diagnoses.

FUNCTIONAL DIMENSION


NRS Case-Mix Adjustment Variables and Scores

Item Description Score

1 Primary diagnosis = Anal fissure, fistula and abscess 152 Other diagnosis = Anal fissure, fistula and abscess 133 Primary diagnosis = Cellulitis and abscess 144 Other diagnosis = Cellulitis and abscess 85 Primary diagnosis = Diabetic ulcers 206 Primary diagnosis = Gangrene 117 Other diagnosis = Gangrene 88 Primary diagnosis = Malignant neoplasms of skin 159 Other diagnosis = Malignant neoplasms of skin 4

10 Primary or Other diagnosis = Non-pressure and non-stasis ulcers 1311 Primary diagnosis = Other infections of skin and subcutaneous tissue 1612 Other diagnosis = Other infections of skin and subcutaneous tissue 713 Primary diagnosis = Post-operative Complications 2314 Other diagnosis = Post-operative Complications 1515 Primary diagnosis = Traumatic Wounds and Burns 1916 Other diagnosis = Traumatic Wounds and Burns 817 Primary or other diagnosis = V code, Cystostomy care 1618 Primary or other diagnosis = V code, Tracheostomy care 2319 Primary or other diagnosis = V code, Urostomy care 2420 OASIS M1322 = 1 or 2 pressure ulcers, stage 1 421 OASIS M1322 = 3+ pressure ulcers, stage 1 622 OASIS M1308 = 1 pressure ulcer, stage 2 1423 OASIS M1308 = 2 pressure ulcers, stage 2 2224 OASIS M1308 = 3 pressure ulcers, stage 2 2925 OASIS M1308 = 4+ pressure ulcers, stage 2 3526 OASIS M1308 = 1 pressure ulcer, stage 3 2927 OASIS M1308 = 2 pressure ulcers, stage 3 4128 OASIS M1308 = 3 pressure ulcers, stage 3 4629 OASIS M1308 = 4+ pressure ulcers, stage 3 5830 OASIS M1308 = 1 pressure ulcer, stage 4 4831 OASIS M1308 = 2 pressure ulcers, stage 4 6732 OASIS M1308 = 3+ pressure ulcers, stage 4 7533 OASIS M1308 Unstageable Dressing/Device OR Unstageable Slough/Eschar = 1+ 1734 OASIS M1332 = 2 (2 stasis ulcers) 635 OASIS M1332 = 3 (3 stasis ulcers) 1236 OASIS M1332 = 4 (4+ stasis ulcers) 2137 OASIS M1330 = 1 or 3 (unobservable stasis ulcers) 938 OASIS M1334 = 1 (status of most problematic stasis ulcer: fully granulating) 639 OASIS M1334 = 2 (status of most problematic stasis ulcer: early/partial granulation) 2540 OASIS M1334 = 3 (status of most problematic stasis ulcer: not healing) 3641 OASIS M1342 = 2 (status of most problematic surgical wound: early/partial granulation) 442 OASIS M1342 = 3 (status of most problematic surgical wound: not healing) 14

43 OASIS M1630=1(ostomy not related to inpt stay/no regimen change) 2744 OASIS M1630 =2 (ostomy related to inpt stay/regimen change) 4545 Any `Selected Skin Conditions` (rows 1-42 above) AND M1630=1(ostomy not related to inpt stay/no 1446 Any `Selected Skin Conditions` (rows 1-42 above) AND M1630=2(ostomy related to inpt stay/ regimen 1147 OASIS M1030 (Therapy at home) =1 (IV/Infusion) 548 OASIS M1610 = 2 (patient requires urinary catheter) 949 OASIS M1620 = 4 or 5 (bowel incontinence, daily or >daily) 10

SELECTED SKIN CONDITIONS:

OTHER CLINICAL FACTORS:



(M1020/1022/1024)

Diagnoses, Symptom Control, and Payment Diagnoses: List each diagnosis for which the patient is receiving home care

(Column 1) and enter its ICD-9-C M code at the level of highest specificity (no surgical/procedure codes) (Column 2).

Diagnoses are listed in the order that best reflect the seriousness of each condition and support the disciplines and services

provided. Rate the degree of symptom control for each condition (Column 2). Choose one value that represents the

degree of symptom control appropriate for each diagnosis: V-codes (for M1020 or M1022) or E-codes (for M1022 only)

may be used. ICD-9-C M sequencing requirements must be followed if multiple coding is indicated for any diagnoses. If a

V-code is reported in place of a case mix diagnosis, then optional item M1024 Payment Diagnoses (Columns 3 and 4) may

be completed. A case mix diagnosis is a diagnosis that determines the Medicare P P S case mix group. Do not assign

symptom ratings for V- or E- codes.

Code each row according to the following directions for each column:

Column 1: Enter the description of the diagnosis.

Column 2: Enter the ICD-9-C M code for the diagnosis described in Column 1;

Rate the degree of symptom control for the condition listed in Column 1 using the following scale:

0 - Asymptomatic, no treatment needed at this time

1 - Symptoms well controlled with current therapy

2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring

3 - Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring

4 - Symptoms poorly controlled; history of re-hospitalizations

Note that in Column 2 the rating for symptom control of each diagnosis should not be used to determine the sequencing

of the diagnoses listed in Column 1. These are separate items and sequencing may not coincide. Sequencing of

diagnoses should reflect the seriousness of each condition and support the disciplines and services provided.

Column 3: (OPTIONAL) If a V-code is assigned to any row in Column 2, in place of a case mix diagnosis, it may be

necessary to complete optional item M1024 Payment Diagnoses (Columns 3 and 4). See OASIS-C Guidance

Manual.

Column 4: (OPTIONAL) If a V-code in Column 2 is reported in place of a case mix diagnosis that requires multiple diagnosis

codes under ICD-9-C M coding guidelines, enter the diagnosis descriptions and the ICD-9-C M codes in the same

row in Columns 3 and 4. For example, if the case mix diagnosis is a manifestation code, record the description

and ICD-9-C M code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row.

(M1020) Primary Diagnosis & (M1022) Other Diagnosis (M1024) Payment Diagnoses (OPTIONAL)

Column 1 Column 2 Column 3 Column 4

Diagnoses(Sequencing of diagnoses should

reflect the seriousness of eachcondition and support the

disciplines and services provided)

ICD-9-C M and symptom controlrating for each condition.

Note that the sequencing of theseratings may not match the

sequencing of the diagnoses

Complete if a V-code is assignedunder certain circumstances to

Column 2 in place of a case mixdiagnosis.

Complete only if the V-code inColumn 2 is reported in place of

a case mix diagnosis that is amultiple coding situation (e.g., a

manifestation code).

Description ICD-9-C M /Symptom Control Rating



(M 1020) Primary Diagnosis

a.

(V-codes are allowed)

a. (__ __ __ - __ __)

9 0 9 1 9 2 9 3 9 4

(V- or E-codes NOT allowed)

a.

(__ __ __ - __ __)

(V- E-codes NOT allowed)

a.

(__ __ __ - __ __)

(M1022) Other Diagnoses

b.

(V- or E-codes are allowed)

b. (__ __ __ - __ __)

9 0 9 1 9 2 9 3 9 4

(V- or E-codes NOT allowed)

b.

(__ __ __ - __ __)

(V- E-codes NOT allowed)

b.

(__ __ __ - __ __)

c. c. (__ __ __ - __ __)

9 0 9 1 9 2 9 3 9 4

c.

(__ __ __ - __ __)

c.

(__ __ __ - __ __)

d. d. (__ __ __ - __ __)

9 0 9 1 9 2 9 3 9 4

d.

(__ __ __ - __ __)

d.

(__ __ __ - __ __)

e. e. (__ __ __ - __ __)

9 0 9 1 9 2 9 3 9 4

e.

(__ __ __ - __ __)

e.

(__ __ __ - __ __)

f. f. (__ __ __ - __ __)

9 0 9 1 9 2 9 3 9 4

f.

(__ __ __ - __ __)

f.

(__ __ __ - __ __)