ICD-10 CODING CHANGES WITHOUT AN OASIS ASSESSMENT IN PDGM?

ICD-10 Coding Changes Without an OASIS Assessment in PDGM?

During the last Home Health Patient-Driven Grouping Model: Operational issues call from CMS, several issues were clarified.  However, one issue may be causing more confusion among providers already searching for solutions to operational changes for PDGM. This is the potential to change ICD-10 diagnosis coding on the claim without submitting an updated OASIS.  CMS made the following statements:

  • No edits in Medicare systems comparing claim and OASIS diagnosis codes
  • No need to complete an ‘other follow-up’ SCIC (RFA 05) just to ensure claim and OASIS coding match
  • Complete an ‘other follow-up’ SCIC (RFA 05) assessment when a change would be considered a major decline or improvement in the patient’s health status
  • Under the PDGM, claims are the source of record for payment diagnosis codes, not OASIS
  • If diagnosis codes change during a period of care (before the “From” date of the next period), the coding changes should be reflected on the claim on the next period

https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2019-08-21-HH-PDGM-Presentation.pdf

The COP guidelines instructing providers use the same language regarding the ‘other follow-up’ SCIC (RFA 05);

484.55(d)Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status……

CMS-3819-F Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies

Interpretive Guidelines

Agencies who are on the fence about doing the 'other follow-up' SCIC (RFA 05) need to consider the following; if there has been a major decline in the patient’s health status, that will likely include a decline in the patient’s overall functional scores. Without the SCIC, the agency will not capture the functional points.

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