Editor’s note: Today’s post concludes our four-part series on common home health coding errors. If you’d like to receive more home health coding tips in your Inbox each week, sign up for our free email, The Monday Fix.
Seeing existing codes in a patient’s medical record can sometimes be distracting to home health coders, particularly novice coders who don’t yet feel confident in their own judgment. It’s tempting to look at the codes someone else has assigned, and use those codes as a starting point.
But those codes can be misleading — especially if they were assigned prior to the patient’s admittance to home health, during treatment in an inpatient facility, where the coding rules may be different.
Home health coders need to be wary of any previously assigned codes encountered in the medical record, focusing instead on assigning new codes directly from the M.D.’s written notes.
Codes from skilled nursing facilities, wound care centers or clinics may have little bearing on the home health episode. Coding guidelines for those facilities can sometimes differ in important ways from coding guidelines for home health — and in some cases, codes from facilities may not be specific enough.
As an example, if a patient with Type 2 diabetes and peripheral neuropathy has been referred to home health, the skilled nursing facility where the patient was treated may have selected E11.9 (Type 2 diabetes without complications) as the code. If documentation from the M.D. during the patient’s hospital stay establishes that the patient has peripheral neuropathy due to diabetes, E.11.9 would not be the correct code. The coder would need to select E11.42.
Written notes from the M.D. supercede any code selected by any facility. Keep your eyes on those written notes, coding only from what has been documented there, and it becomes easier to avoid a coding error.
This was the fourth in a series of blog posts about common coding errors. Did you miss any of these other posts?
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