Understanding Diagnosis Coding in PDGM for Compliance

and Optimum Financial Performance

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Understanding Diagnosis Coding in PDGM for

Compliance and Optimum Financial
Performance

The art of life is a constant

readjustment to our surroundings. -
-
Kakuzo Okakaura

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TABLE OF CONTENTS

Explain the Impact of Coding under 
PGDM

Evaluate the specificity requirements of 
coding under PDGM

What your agency should be doing now 
to prepare for coding under PDGM
© 2019 5 Star Consultants, LLC
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PDGM – Payment Groupings Overview\

• CY 2019 Home Health final rule, PDGM will be implemented for 30-day periods of
care starting on or after January 1, 2020

– PDGM uses 30-day periods as a basis for payment.

– 30-day periods are categorized into 432 case-mix groups for the purposes of
adjusting payment in PDGM.

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PDGM - Subgroups

• 30-day periods are placed into different subgroups for each of the following
categories:

– Admission source (two subgroups):

• Community or
• Institutional admission source

– Timing of the 30-day period (two subgroups):

• Early (first 30-day period) or
• Late (every subsequent payment period after the first period)

PDGM - Subgroups
• Clinical Grouping - Twelve groups based on Primary diagnosis:
– Musculoskeletal Rehabilitation
– Neuro/Stroke Rehabilitation
– Wounds
– Behavioral Health Care
– Complex Nursing Interventions
– MMTA - Surgical Aftercare
– MMTA - Cardiac and Circulatory
– MMTA - Endocrine
– MMTA - Gastrointestinal Tract and Genitourinary System
– MMTA - Infectious Disease, Neoplasms, and Blood-Forming Diseases
– MMTA - Respiratory
– MMTA - Other

Note: MMTA = Medication Management, Teaching, Assessment

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PDGM - Subgroups

• Functional Impairment Level (three subgroups)

• Low, Medium, or High-based on the OASIS responses to:

– M1800 - grooming
– M1810 - upper body dressing
– M1820 - lower body dressing
– M1830 - bathing
– M1840 - toilet transferring
– M1850 - transferring
– M1860 - ambulation/locomotion
– M1033 - hospitalization risk - *excluding responses 8-reports exhaustion, 9-
risk(s) not listed in 1-8, and 10-none of the above
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PDGM - Subgroups

• Comorbidity Adjustment
– From Secondary Diagnosis Reported on Claims
• None
• Low
• High

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Patient-Driven Groupings Model (PDGM)

PDGM Coding Impacts

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Coding Impact on PDGM Groupings Model

• 2 of the 5 categories are based on the diagnoses coding

– Clinical Grouping
• From Principal Diagnosis Reported on Claim
– Comorbidity Adjustment
• From Secondary Diagnoses Reported on Claim

• Clinical Group Coding

– Key component of determining payment in PDGM is the 30-day period’s clinical
group assignment
• Based on the principal diagnosis code for the patient as reported by the HHA
on the home health claim.

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PDGM Clinical Groups

TABLE 6: PDGM CLINICAL GROUPS

CLINICAL GROUP PRIMARY REASON FOR HOME HEALTH ENCOUNTER IS TO PROVIDE:
Musculoskeletal Rehabilitation Therapy (PT/OT/SLP) for a musculoskeletal condition
Neuro/Stroke Rehabilitation Therapy (PT/OT/SLP) for a neurological condition or stroke
Wounds ‐ Post‐Op Wound 
Assessment, treatment and evaluation of a surgical wound(s); assessment, treatment and evaluation of non‐surgical 
Aftercare and Skin/ Non‐Surgical 
wounds, ulcers burns and other lesions
Wound Care
Behavioral Health Care Assessment, treatment and evaluation of psychiatric and substance abuse conditions
Assessment, treatment and evaluation of complex medical and surgical conditions including IV, TPN, enteral, 
Complex Nursing Interventions
nutrition, ventilator, and ostomies
Medication Management, Teaching and Assessment (MMTA)
MMTA –Surgical Aftercare Assessment, evaluation, teaching, and medication management for Surgical Aftercare
MMTA – Cardiac/Circulatory Assessment, evaluation, teaching, and medication management for Cardiac or other circulatory related conditions
MMTA – Endocrine Assessment, evaluation, teaching, and medication management for Endocrine related conditions
Assessment, evaluation, teaching, and medication management for Gastrointestinal or Genitourinary related 
MMTA – GI/GU
condition
MMTA – Infectious 
Assessment, evaluation, teaching, and medication management for conditions related to Infectious 
Disease/Neoplasms/ Blood‐
diseases/Neoplasms/ Blood‐forming Diseases
forming Diseases
MMTA –Respiratory Assessment, evaluation, teaching, and medication management for Respiratory related conditions
Assessment, evaluation, teaching, and medication management for a variety of medical and surgical conditions not 
MMTA – Other
classified in one of the previously listed groups
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Reference: Federal Register/Vol. 84, No. 138/Thursday, July 18, 2019/Proposed Rules 

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PDGM - Comorbidity Coding

• OASIS only allows HHAs to designate 1 primary diagnosis and 5 secondary

diagnoses, however, the home health claim allows HHAs to designate 1 principal
diagnosis and 24 secondary diagnoses.

• All 24 secondary diagnoses can impact reimbursement

• The comorbidity adjustment in PDGM can increase payment by up to 20 percent.

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PDGM - Comorbidity Coding

• 30-day periods of care can receive a comorbidity adjustment under the following
circumstances:
– No comorbidity adjustment:
• No secondary diagnoses exist, or none meet the criteria for a low or high
comorbidity adjustment

– Low comorbidity adjustment:

• There is a secondary diagnosis on the HH-specific comorbidity subgroup list that is
associated with higher resource use.

– High comorbidity adjustment:

• 2 or more secondary diagnoses on the HH-specific comorbidity subgroup
interaction list that are associated with higher resource use when both are reported
together compared to if they were reported separately.
– The two diagnoses may interact with one another, resulting in higher
resource use.

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PDGM - Comorbidity Adjustment

• Only one comorbidity adjustment is permitted

– A 30-day period of care can receive only one low comorbidity adjustment or one
high comorbidity adjustment
• Regardless of the number of secondary diagnoses or high comorbidity
subgroup interactions reported on the claim
– The highest level will be assigned

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PDGM - Comorbidity Adjustment

• 12 comorbidity subgroups receive the low comorbidity adjustment

• 34 comorbidity subgroup interactions receive the high comorbidity adjustment, as

noted in the tables on the following slides

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PDGM -Low Comorbidity Adjustment Subgroups

Reference: Federal Register/Vol. 84, No. 138/Thursday, July 18, 2019/Proposed Rules 
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PDGM - High Comorbidity Adjustment Interaction

Subgroups
Comorbidity 
Comorbidity  Comorbidity 
Subgroup  Description Description
Subgroup Subgroup
Interaction
Includes diseases of arteries, arterioles, and capillaries with ulceration 
1 Behavioral 2 Includes depression and bipolar disorder Skin 3
and non‐pressure, chronic ulcers
Includes sequelae of cerebral vascular 
2 Cerebral 4 Circulatory 4 Includes hypertensive chronic kidney disease
diseases
Includes sequelae of cerebral vascular 
3 Cerebral 4 Heart 11 Includes heart failure
diseases
Includes sequelae of cerebral vascular 
4 Cerebral 4 Neuro 10 Includes peripheral and polyneuropathies
diseases
Includes hypertensive chronic kidney 
5 Circulatory 4 Skin 1 Includes cutaneous abscess, cellulitis, lymphangitis
disease
Includes hypertensive chronic kidney  Includes diseases of arteries, arterioles, and capillaries with ulceration 
6 Circulatory 4 Skin 3
disease and non‐pressure, chronic ulcers
Includes hypertensive chronic kidney 
7 Circulatory 4 Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers
disease
Includes diseases of arteries, arterioles, and capillaries with ulceration 
8 Circulatory 7 Includes atherosclerosis Skin 3
and non‐pressure, chronic ulcers
9 Endocrine 3 Includes diabetes with complications Neuro 5 Includes Parkinson's disease
10 Endocrine 3 Includes diabetes with complications Neuro 7 Includes hemiplegia, paraplegia, and quadriplegia

11 Endocrine 3 Includes diabetes with complications Skin 1 Includes cutaneous abscess, cellulitis, lymphangitis

Includes diseases of arteries, arterioles, and capillaries with ulceration 
12 Endocrine 3 Includes diabetes with complications Skin 3
and non‐pressure, chronic ulcers 18
Reference: Federal Register/Vol. 84, No. 138/Thursday, July 18, 2019/Proposed Rules 

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PDGM - High Comorbidity Adjustment Interaction

Subgroups

Comorbidity 
Comorbidity  Comorbidity 
Subgroup  Description Description
Subgroup Subgroup
Interaction

Includes diseases of arteries, arterioles, and capillaries with ulceration and non‐
13 Heart 10 Includes cardiac dysrhythmias Skin 3
pressure, chronic ulcers

14 Heart 10 Includes cardiac dysrhythmias Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers

15 Heart 11 Includes heart failure Neuro 10 Includes peripheral and polyneuropathies

16 Heart 11 Includes heart failure Neuro 5 Includes Parkinson's disease
17 Heart 11 Includes heart failure Skin 1 Includes cutaneous abscess, cellulitis, lymphangitis

Includes diseases of arteries, arterioles, and capillaries with ulceration and non‐
18 Heart 11 Includes heart failure Skin 3
pressure, chronic ulcers

19 Heart 11 Includes heart failure Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers

Includes diseases of arteries, arterioles, and capillaries with ulceration and non‐
20 Heart 12 Includes other heart diseases Skin 3
pressure, chronic ulcers

21 Heart 12 Includes other heart diseases Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers

Reference: Federal Register/Vol. 84, No. 138/Thursday, July 18, 2019/Proposed Rules  19

PDGM - High Comorbidity Adjustment Interaction

Subgroups

Comorbidity 
Comorbidity  Comorbidity 
Subgroup  Description Description
Subgroup Subgroup
Interaction

22 Neuro 10 Includes peripheral and polyneuropathies Neuro 5 Includes Parkinson's disease

Includes diseases of arteries, arterioles, and capillaries with ulceration and non‐
23 Neuro 10 Includes peripheral and polyneuropathies Skin 3
pressure, chronic ulcers

Includes diseases of arteries, arterioles, and capillaries with ulceration and non‐
24 Neuro 3 Includes dementia Skin 3
pressure, chronic ulcers

25 Neuro 3 Includes dementia Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers

26 Neuro 5 Includes Parkinson's disease Renal 3 Includes nephrogenic diabetes insipidus

Includes hemiplegia, paraplegia, and 
27 Neuro 7 Renal 3 Includes nephrogenic diabetes insipidus
quadriplegia

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Reference: Federal Register/Vol. 84, No. 138/Thursday, July 18, 2019/Proposed Rules 

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PDGM - High Comorbidity Adjustment Interaction

Subgroups

Comorbidity Subgroup  Comorbidity 
Description Comorbidity Subgroup Description
Interaction Subgroup

Includes diseases of arteries, arterioles, and capillaries with 
28 Renal 1 Includes chronic kidney disease and ESRD Skin 3
ulceration and non‐pressure, chronic ulcers

Includes Stages Two Through Four and Unstageable 
29 Renal 1 Includes chronic kidney disease and ESRD Skin 4
Pressure ulcers

Includes Stages Two Through Four and Unstageable 
30 Renal 3 Includes nephrogenic diabetes insipidus Skin 4
Pressure ulcers

Includes diseases of arteries, arterioles, and capillaries with 
31 Resp 5 Includes COPD and asthma Skin 3
ulceration and non‐pressure, chronic ulcers

Includes Stages Two Through Four and Unstageable 
32 Resp 5 Includes COPD and asthma Skin 4
Pressure ulcers

Includes diseases of arteries, arterioles, and capillaries with 
33 Skin 1 Includes cutaneous abscess, cellulitis, lymphangitis Skin 3
ulceration and non‐pressure, chronic ulcers

Includes diseases of arteries, artcrioles, and capillaries  Includes Stages Two Through Four and Unstageable 
34 Skin 3 Skin 4
with ulceration and non‐pressure, chronic ulcers Pressure ulcers

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Reference: Federal Register/Vol. 84, No. 138/Thursday, July 18, 2019/Proposed Rules 

PDGM - Comorbidity Adjustment Example

• Low comorbidity adjustment

• Example
• Secondary diagnosis of I50.9 Heart failure, unspecified
• No additional comorbid diagnoses on the claim that fall into a Low or High
Comorbidity Subgroup
• I50.9 falls into Low Comorbidity Subgroup - Heart 11

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PDGM - Comorbidity Adjustment Example

• High comorbidity adjustment

• Example
– I50.32 Chronic diastolic (congestive) heart failure-Comorbidity Group Heart
11 and G20 Parkinson's disease- Comorbidity Group Neuro 5
• Both of these diagnoses when reported on the same claim fall within one of
the 34 high comorbidity adjustment interaction subgroups -16

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Low Comorbidity – Coding Scenario

• Referral from the hospital for Mr. Smith after he was admitted for a wound to his right
calf
• Per the physician documentation, the patient has stasis dermatitis and developed a
stasis ulcer to the right calf that currently has the fat layer exposed.
• The patient also has a diagnosis of hypertension
• The referral is for wound care twice a week.

Question
– How would you code the Primary and Secondary Diagnoses based on the above
scenario?

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Low Comorbidity – Coding Scenario – Answer

• Primary Diagnosis:
– I87.2 Venous insufficiency (chronic) (peripheral) - MMTA-CARDIAC
• This diagnosis is primary per coding guidelines- the associated underlying
condition is coded first followed by the appropriate L97 code

• Secondary Diagnoses:
– L97.212 Non-pressure chronic ulcer of right calf with fat layer exposed –
Comorbidity Subgroup Skin 3
– I10 Essential (primary) hypertension – No Comorbidity Subgroup

• Low Comorbidity Adjustment - there is a reported secondary diagnosis, L97.212, that

falls within one of the HH specific individual comorbidity subgroups - Skin 3

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Low Comorbidity – Coding Scenario

First 30-Day Period
• First 30-day period

• Scenario based on:

– Admission Source – Institutional
– Timing – Early
– Clinical Group – MMTA-CARDIAC
– Functional Impairment Level – Low
– Comorbidity Adjustment - Low
• HIPPS of 2HA21, Case Mix weight of 1.2138, LUPA threshold of 4, Payment
$2,536

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Low Comorbidity – Coding Scenario

Second 30-Day Period
• Second 30-day period with no changes in diagnoses

• Scenario based on:

– Admission Source – Community
– Timing – Late
– Clinical Group – MMTA-CARDIAC
– Functional Impairment Level – Low
– Comorbidity Adjustment - Low

• HIPPS of 3HA21, Case Mix Weight of 0.6277, LUPA threshold of 2, Payment -

$1,311

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High Comorbidity - Coding Scenario

• Mrs. Adams was discharged from the hospital, where she was newly diagnosed with
acute exacerbation of diastolic CHF. While hospitalized, she was noted to have a
Stage 2 pressure ulcer to her coccyx.
• She has history of hypertension.
• Physician referred to home health to monitor cardiac status and BP, teach disease
process CHF, and wound care to pressure ulcer

Question
• How would you code the Primary and Secondary Diagnoses based on the above
scenario?

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High Comorbidity Coding Scenario - Answer

• Primary Diagnosis:
– I11.0 Hypertensive heart disease with heart failure – Clinical Group MMTA-
CARDIAC

• Secondary Diagnoses:
• I50.31 Acute diastolic (congestive) heart failure - Comorbidity Subgroup
Heart 11
• L89.152 Pressure ulcer of sacral region, stage 2 - Comorbidity Subgroup
Skin 4

• High Comorbidity adjustment - there 2 or more secondary diagnoses that fall within
one or more of the comorbidity interaction subgroups – subgroup 19 - Heart 11/Skin
4

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High Comorbidity – Coding Scenario

First 30-Day Period
• First 30-day period

• Scenario based on:

– Admission Source – Institutional
– Timing – Early
– Clinical Group – MMTA-CARDIAC
– Functional Impairment Level – Low
– Comorbidity Adjustment – High

• HIPPS of 2HA31, case mix weight of 1.3389, LUPA threshold of 4, and payment of
$2,797

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High Comorbidity – Coding Scenario

Second 30-Day Period
• Second 30-day period with no diagnoses changes

• Scenario based on:

– Admission Source – Community
– Timing – Late
– Clinical Group – MMTA-CARDIAC
– Functional Impairment Level – Low
– Comorbidity Adjustment – High

• HIPPS of 3HA31, case mix weight of 0.7528, LUPA threshold of 3, and payment of
$1,573

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High Comorbidity - Coding Scenario

• Mr. Jones is seen in physician office after being discharged from the hospital 2 days
ago, where he was treated for exacerbation of COPD and elevated BP.
• He continues to take decreasing doses of prednisone. BP elevated at physician
appointment and physician increased dose of Lisinopril.
• Patient complained of pain on his bottom when sitting- found to have Stage 2
pressure ulcer of the coccyx.
• He has history of CHF, Atrial Fib, Parkinson’s Disease, & he is taking Coumadin.
• Physician referred to HH- wound care to pressure ulcer 3x/week, monitor resp status,
monitor BP, response to med change & ordered PT/INR.

Question
– How would you code the Primary and Secondary Diagnoses based on the above
scenario?

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High Comorbidity Coding Scenario - Answer

• Primary Diagnosis:
– L89.152 Pressure ulcer of sacral region, stage 2- Clinical Group WOUND
– This diagnosis is primary as it requires the most intensive skilled service

• Secondary Diagnoses:
– J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation- Comorbidity
Subgroup Resp 5
– I11.0 Hypertensive heart disease with heart failure - Comorbidity Subgroup Heart 11
– I50.9 Heart failure, unspecified - Comorbidity Subgroup Heart 11
– I48.91 Unspecified atrial fibrillation - Comorbidity Subgroup Heart 10
– G20 Parkinson’s Disease - Comorbidity Subgroup Neuro 5
– Z51.81 Encounter for therapeutic drug level monitoring - Not in Clinical Grouping
– Z79.01 Long term (current) use of anticoagulants - Not in Clinical Grouping
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High Comorbidity – Coding Scenario

• This scenario would receive a High Comorbidity adjustment - there 2 or more

secondary diagnoses that fall within one or more of the comorbidity interaction
subgroups – subgroup 16 - Heart 11/Neuro 5
– As you can see, it is important to list all diagnoses that affect the plan of care

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High Comorbidity – Coding Scenario

First 30- Day Period
• First 30-day period

• Scenario based on:

– Admission Source – Institutional
– Timing – Early
– Clinical Group – Wound
– Functional Impairment Level – Low
– Comorbidity Adjustment – High

• HIPPS of 2CA31, case mix weight of 1.5865, LUPA threshold of 4, and payment of
$3,314

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High Comorbidity – Coding Scenario

Second 30-Day Period
• Second 30-day period with no diagnoses changes

• This scenario based on:

– Admission Source – Community
– Timing – Late
– Clinical Group – Wound
– Functional Impairment Level – Low
– Comorbidity Adjustment – High

• HIPPS of 3CA31, case mix weight of 1.0005, LUPA threshold of 3, and payment of
$2,090

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PDGM – Comorbidity Coding

• ICD – 10 Coding Guidelines require reporting of all secondary (additional) diagnoses

that affect the plan of care

• New Language "Secondary diagnoses are only to be reported if they are conditions
that affect patient in terms of requiring clinical evaluation; therapeutic
treatment; diagnostic procedures; extended length of hospital stay; or increased
nursing care and/or monitoring"
– Previous language "potentially affect the patient's care“

• New Language "We do not expect that HHAs would report comorbid conditions that
are not being addressed in the individualized plan of care"

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PDGM – Comorbidity Coding- Sequencing

• Place diagnoses in order to best reflect the seriousness of the patient’s condition and
to justify the disciplines and services in accordance with the ICD -10 Coding
Guidelines

• Be sure to Sequence of codes following ICD guidelines for reporting: Manifestation

codes, 'Code First', Excludes 1 Notes

• Medicare does not have any additional requirements regarding the reporting or
sequence of the codes beyond those contained in ICD guidelines.

Reference:  CMS Transmittal 4312, dated, May 23, 2019  38
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PDGM – Comorbidity Coding

• Case-mix variables in PDGM work in tandem to

– Account for the complexity of patient care needs
– Make payment for home health services accordingly

• Follow Coding Guidelines and code to what the physician documents and the
OASIS assessment indicates is appropriate!

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PDGM
“Unaccepted Diagnosis”

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PDGM - "Unaccepted Diagnosis"

• Based on the primary diagnosis, each 30-day period will be placed into one of the 12
clinical groupings

• If the primary diagnosis does not fit into one of the 12 clinical groups in the payment
model, this is considered an "Unaccepted Diagnosis"

• These were formerly called, “Questionable Encounters”

– Keep in mind that “UD” or “QE” means a patient’s diagnosis isn’t appropriate for
a Medicare Home Health encounter!

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PDGM - "Unaccepted Diagnosis"

• Submission of an "Unaccepted Diagnosis"

– If a claim is submitted with a primary diagnosis that doesn’t fit into
one of the 12 clinical groupings, the claim will be sent back to the
agency as an “RTP”- Return to Provider.
– The agency will then need to review & resubmit the claim with a more
appropriate primary diagnosis which does fit into a clinical grouping.

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PDGM - "Unaccepted Diagnosis"

• Complete list of ICD–10–CM codes and their assigned clinical groupings is found on
the CMS HHA Center web page - https://www.cms.gov/center/provider-type/home-
health-agency-hha-center.html
• Become familiar with codes that would be used to group 30- day periods of
care into the 12 clinical groupings
• Number of returned claims should be minimal
– Avoid listing codes as the principal diagnosis code on the claim that are
known "unaccepted diagnosis"
– Diagnoses that will not be allowed as a primary diagnosis for Medicare
under PDGM may be allowed as primary diagnoses for other insurances.

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5 Star Consultants
Unaccepted Diagnosis Top 10 Codes
• M62.81 Muscle Weakness (Generalized)
• M54.5 Low back pain
• R26.81 Unsteadiness on Feet
• R26.89 Other abnormalities of gait and mobility
• R53.1 Weakness
• G62.9 Polyneuropathy, unspecified
• R29.6 Repeated falls
• R13.10 Dysphagia, unspecified
• R42 Dizziness and giddiness
• M19.90 Unspecified osteoarthritis, unspecified site

Codes in RED are codes are also in the top unaccepted codes found industry wide.

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Commonly Used Unaccepted Diagnosis Codes

• L03.90 Cellulitis, unspecified

• L89.--9 Pressure ulcer with unspecified stage
• L98.9 Disorder of the skin and subcutaneous tissue, unspecified
• M06.9 Rheumatoid arthritis, unspecified
– Alternative code-M06.89-Other specified rheumatoid arthritis, multiple sites
• M25.551 Pain in right hip
• M25.552 Pain in left hip
• M25.651 Pain in right knee
• M25.652 Pain in left knee

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Commonly Used Unaccepted Diagnosis Codes

• M48.00 Spinal stenosis, site unspecified

• M54.30 Sciatica, unspecified side
• M62.50 Muscle wasting and atrophy, not elsewhere classified, unspecified site
– Code for muscle wasting must include site to be accepted as a primary diagnosis
• R26.0 Ataxic gait
• R27.8 Other lack of coordination
• R33.9 Retention of urine, unspecified
• R55 Syncope and collapse
• R25.9 Unspecified convulsions
• S06.9X9D Unspecified intracranial injury with loss of consciousness of unspecified duration
• Z48.89 Encounter for other specified surgical aftercare
• Z51.81 Encounter for therapeutic drug level monitoring
• Z51.89 Encounter for other specified aftercare
• Z91.81 History of falling
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Commonly Used Unaccepted Diagnosis Codes

• Many codes that end with the character "9" are unaccepted diagnosis codes as these
codes indicate unspecified sites, or unspecified diseases

• Remember - Unacceptable Diagnoses Can be Secondary Diagnoses!

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Resolving an Unaccepted Diagnosis Code

• Review documentation thoroughly to see if specific disease information is included

• Query the physician for:

– Specific disease information
– Underlying cause of a symptom
• Condition causing, for example, Muscle Weakness

• The clinician can determine the site of an issue, such as a wound, and
verify/confirm the information with the physician

• Communication, Communication, Communication!

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PDGM Coding Specificity

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Coding Specificity:

• Most specific code that describes a medical disease, condition, or injury

should be selected.

• ‘‘Unspecified’’ codes are used when there is lack of information about

location or severity of medical conditions in the medical record.

• BUT……you are to use a precise code whenever more specific codes

are available.

• If additional information regarding the diagnosis is needed, follow-up with

the referring provider in order to ensure the Plan of Care (POC) is
sufficient in meeting the needs of the patient.

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Coding Specificity:

• Many of the codes that indicate pain or contractures as the primary diagnosis, ex:
M54.5, Low back pain or M62.422, Contracture of muscle, right hand, is site specific,
but doesn’t indicate the cause of the pain or contracture.

• CMS expects a more definitive diagnosis indicating the cause of the pain or
contracture, as the reason for the skilled care, in order to appropriately group the
home health period.

Reference: Federal Register/Vol. 83, No. 219/Tuesday, November 13, 2018/Rules and Regulations 51
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CMS - Coding Specificity: Muscle Weakness

• M62.81, ‘‘Muscle weakness, generalized’’ is extremely vague, therefore,

will not be accepted as a Primary Diagnosis under PDGM
– “Generalized muscle weakness, while obviously a common condition
among recently hospitalized patients, does not clearly support a
rationale for skilled services and does not lend itself to a
comprehensive plan of care.”

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CMS - Coding Specificity: Muscle Weakness

• 2008 HH PPS final rule, CMS- ‘‘Muscle Weakness (generalized)’’ is a

nonspecific condition that represents general symptomatic complaints in
the elderly population.

• CMS stated that inclusion of this code ‘‘would threaten to move the case-
mix model away from a foundation of reliable and meaningful diagnosis
codes that are appropriate for home care’’ (72 FR 49774).

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Coding Specificity: Use of R Codes

• R codes- that describe signs and symptoms, as opposed to diagnoses-

are Unacceptable Diagnoses as principal diagnosis codes

• Use of symptoms, signs, abnormal clinical & lab findings make it difficult
to meet the requirements of an individualized plan of care (CoPs).

• Clinically, it is important for HH clinicians to have a clearer understanding

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

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Coding Specificity: Use of R Codes

• Coding guidelines- R codes are to be used when no more specific

diagnosis can be made.

• By the time the patient is referred to home health and meets the
qualifications of eligibility, a more definitive code should exist to
substantiate the need for services.

• This may involve calling the referring physician to gather more

information.

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Coding Specificity: Use of S and T Codes

• There are many S and T codes where the fracture and/or injury is
unspecified, but the site is specified.

• The site of injury and/or fracture should be identified

• The treatment or intervention would likely not change based on the exact
type of injury or fracture.

• Many of these codes are appropriate to group into a clinical group, and
are either in the musculoskeletal group or the wounds group.

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Coding Specificity: Sepsis

• A sepsis diagnosis should be assigned the appropriate code for the

underlying systemic infection.
– These codes will be classified under MMTA—Infectious
Disease/Neoplasms/Blood-forming Diseases

NOTE:
• In a case where the patient is receiving an IV antibiotic for sepsis, the
HHA is required to code sepsis as the primary diagnosis:
• The Z code must be listed as the first secondary diagnosis code
listed on the claim in order to group the period into the Complex
Nursing Interventions group

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Coding Specificity: Use of Z Codes

• Z codes may be used as primary diagnosis

– Z45.2 Encounter for adjustment and management of VAD -
COMPLEX Nursing Interventions
– Z46.6 Encounter for fitting and adjustment of urinary device will be
grouped into the - COMPLEX Nursing Interventions
– Z47.1 Aftercare following joint replacement surgery – MS_REHAB
– Z48.00 Encounter for change or removal of nonsurgical wound
dressings – WOUND
– Z48.812 Encounter for surgical aftercare following surgery on the
circulatory system – MMTA_AFTER

• In addition to the Z codes listed, there are several others- Check in ICD 10
diagnosis list
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PDGM
Primary Diagnosis Coding Changes

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PDGM – Primary Diagnosis Changes

• If the primary diagnosis changes between the 1st & 2nd 30-day periods, then the
claim for the 2nd 30-day period would reflect the new diagnosis
– Code would not change the claim for the first 30-day period

• Case mix group cannot be adjusted within each 30-day period

• For claim "From" dates on or after January 1, 2020, the ICD-10 code & principle
diagnosis used for payment grouping will be from the claim coding rather than the
OASIS item.

• The claim and OASIS diagnosis codes will no longer be expected to match in all
cases.

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PDGM – Primary Diagnosis Changes

• Typically, the codes will match between the 1st claim in an admission & the start of
care (Reason for Assessment –RFA 01) assessment & claims corresponding to
recertification (RFA 04) assessments.

• 2nd 30-day claims in any 60-day period will not necessarily match the OASIS
assessment.

NOTE: When diagnosis codes change between one 30-day claim and the next, a change
in the diagnoses does not necessarily mean that an ‘‘other follow-up’’ OASIS assessment
(RFA 05) would need to be completed just to make the diagnoses match.

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PDGM – SCIC & Other Follow UP OASIS

• HHA is required to complete an ‘other follow-up’ (RFA 05) assessment when such a
change would be considered a major decline or improvement in the patient’s health
status.

• If a patient experienced a significant change in condition before the start of

a subsequent, contiguous 30-day period, for example due to a fall, in
accordance with 484.55(d)(1)(ii), the HHA is required to update the
comprehensive assessment.

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PDGM
How to Prepare

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What Should Your Agency Be Doing Now To Prepare

For Coding Under PDGM
• It is important to implement changes now and not wait until January 1, 2020

• Revise current coding practices

– Change coding practices now to assure that primary diagnosis codes being used
are approved for use as a primary diagnosis under PDGM.
– All coders should be educated in the list of diagnosis codes in the PDGM
Grouper Tool
– A complete list of ICD–10–CM codes and their assigned clinical groupings is
available on the CMS Home Health Agency (HHA) Center web
page: https://www.cms.gov/center/provider-type/home-health-agency-hha-
center.html

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What Should Your Agency Be Doing Now To Prepare

For Coding Under PDGM
• Education for Staff/ Physicians/ Referral sources
– PDGM coding requirements
• Specificity needed
– Codes that may result in an "Unaccepted Diagnosis"
» R Codes/symptom codes
» Muscle Weakness/Weakness
» Falls
» Difficulty Ambulating/Balance Issues
» "Unspecified" codes
• Physician follow up for additional diagnoses information if needed

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What Should Your Agency Be Doing Now To Prepare

For Coding Under PDGM
• Consider developing a standardized "request for additional diagnosis information "
form for use when additional diagnosis information is needed from the physician
– The form would include an explanation that due to Medicare coding guidelines,
additional documentation for the primary diagnosis is needed
• Primary Diagnosis
• Symptom code
• Specific location
• Wound etiology
– Etc.

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What Should Your Agency Be Doing Now To Prepare

For Coding Under PDGM
• EMR
– Diagnosis coding- will the software allow for secondary diagnosis selection,
beyond the five allowable on the OASIS assessment?
– Functional Impairment Level-OASIS-check for inconsistencies?
– Admission source and timing?
– Will the software estimate HHRG placement and communicate the related LUPA
visit threshold?
– Order Tracking?
– Billing and Claims Management?

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What Should Your Agency Be Doing Now To Prepare

For Coding Under PDGM
• Coding / OASIS Review

• Consider having coding certified/experienced RN’s reviewing the physician

information, OASIS Comprehensive Assessment, and Plan of Care

• Experts to identify Primary Diagnosis that is approved and most accurate for the
Patient

• Communicate to assessing clinician and/or Clinical Manager proactively to query

physician for more specific diagnoses

• Ensure consistencies between OASIS, Plan of Care and physician information

including Face to Face

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Intake Tips
Referral Checklist

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ACT

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Intake Tips

Important:

• Referral Source – where the referral came from

• Admission Source –institutional or community. NEW PDGM

– Institutional source - has a 14-day admission lookback (acute care and post-
acute care)
– Community source – no 14-day prior admission

• Timing - NEW PDGM

– First 30-day period – EARLY
– All subsequent 30-day periods - LATE

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Intake Tips - continued

• Diagnosis Coding
– Gather as much specific documentation as you can at intake.
– Unspecified codes – unaccepted primary code*
– Symptom codes – unaccepted primary code*

• Unaccepted ICD 10 codes (previously called questionable encounter codes) – codes

that are not grouped for home health reimbursement – cannot be used as a primary
diagnosis.

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Intake Referral Checklist Form

• Admission Source
– Admission Source – Community / Institutional (acute care, post-acute care or inpatient
psychiatric hospital in the past 14-days.).
– Has patient received home health services from any agency in the last 30-days
– Has the patient been discharged from a post-acute (SNF/rehab) in the last 30-days
– Admission 14-day lookback (referral source documentation / Medicare Common
working file) for all referrals

• Episode Timing (use Medicare common working file if needed)

• Documentation
– Face to Face Encounter documentation
– Detailed documentation supporting medical necessity/need for home
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Intake Referral Checklist Form - continued

• Diagnosis
– Gather as much specific documentation as you can at intake.
– Detailed diagnosis-specific documentation
• Symptom Codes –need to query physician and/or referral source
• Unspecified Codes -need to query physician and/or referral source
– Be knowledgeable of unaccepted ICD 10 codes
– May need to contact MD for additional documentation for diagnosis

• Reports
– H&P
– Acute and Post-Acute discharge summary reports
– Any other reports

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Conclusion

• Implement coding training now

– Have certified, experienced coders!
• Identify the unaccepted diagnoses you have currently and the root cause behind
them
• Educate referral sources and physicians
– Need Specifics!
• Review your agency processes from intake to discharge to identify any changes
needed in workflow
• Preparation is vital to having a smooth transition into PDGM beginning January 1,
2020!

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Thank You!
Sharon M. Litwin, RN, BSHS, MHA, HCS‐D
Senior Managing Partner
5 Star Consultants, LLC
[email protected]

Contact Us at:
1‐866‐428‐4040

www.5starconsultants.net
You can find us on Facebook and LinkedIn

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