Challenging PDGM Coding Scenarios

6/3/2021
June 4, 2021
Challenging PDGM
Coding Scenarios
Presenter: Sharon M. Litwin RN, BSHS, MHA, HCS-D
HPS Alliance Members Only
Home Health Webinar Series ‐ 2021
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PDGM & Coding
As a result of the implementation of PDGM, we have moved into a new era of
reimbursement
Two of the five PDGM subgroups are directly related to coding.
As we move forward, let's take a deep breath, review what we already
know, and develop a plan to effectively navigate complex coding
scenarios...
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Objectives
UNDERSTAND COMPLEX INTAKE AND REVIEW INTAKE AND CODING DISCUSS ACTION PLANS/BEST

CODING ISSUES SEEN UNDER PDGM SCENARIOS AND CASE STUDIES PRACTICES
Coding Conventions & Guidelines
•Coding Conventions and Guidelines Have not changed
•Follow the conventions and guidelines
•First step in accurate coding
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Intake
•Intake process –
• Need to ensure that No Unacceptable Diagnoses (PDGM) go through to
admission
• Review F2F documentation
• Needs to support primary diagnosis
• Query the physician if additional diagnosis information is needed
•Provide physician/referral source education regarding PDGM
•Informed source will be more willing to provide needed
information
Coding Process
•Code to what the physician documents
•Be sure you have documentation or confirmation from the
physician of a diagnosis before assigning that diagnosis
•Query the physician if additional diagnosis information is
needed
•Code to the comprehensive OASIS assessment, once confirmed with
physician
•The comprehensive assessment and plan of care must support the
diagnoses
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Diagnoses in PDGM
•Primary diagnosis, the primary reason for home health
services, determines the Clinical Group
•The clinical group represents the primary reason for home health
services during a 30‐day period of care
◦ 12 Clinical Groups
•Comorbidity Adjustment
◦ From Secondary Diagnoses reported on the claim (up to 24 allowed)
• None, Low, or High
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 Aftercare and Skin/

Assessment, treatment and evaluation of a surgical wound(s); assessment, treatment and evaluation of non-surgical wounds, ulcers burns and other lesions
Non-Surgical Wound Care
Behavioral Health Care Assessment, treatment and evaluation of psychiatric and substance abuse conditions
Complex Nursing Interventions Assessment, treatment and evaluation of complex medical and surgical conditions including IV, TPN, enteral, 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
MMTA – GI/GU Assessment, evaluation, teaching, and medication management for Gastrointestinal or Genitourinary related condition
MMTA – Infectious Disease/Neoplasms/ Blood-

Assessment, evaluation, teaching, and medication management for conditions related to Infectious diseases/Neoplasms/ Blood-forming Diseases
forming Diseases
MMTA –Respiratory Assessment, evaluation, teaching, and medication management for Respiratory related conditions
MMTA – Other Assessment, evaluation, teaching, and medication management for a variety of medical and surgical conditions not classified in one of the previously listed groups
Reference: Federal Register/Vol. 84, No. 138/Thursday, July 18, 2019/Proposed Rules
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PDGM -Low Comorbidity Adjustment Subgroups

Comorbidity Subgroup Description for Low Comorbidity Subgroups
Cerebral 4 Includes sequelae of cerebral vascular diseases
Circulatory 4 Include hypertensive chronic kidney disease
Circulatory 9 Includes acute and chronic embolisms and thrombosis
Circulatory 10 Includes varicose veins with ulceration

Endocrine 2 Diabetes due to a Known Underlying Condition
Heart 11 Includes heart failure
Neoplasms 1 Includes oral cancers
Neuro 5 Includes Parkinson's disease
Neuro 7 Includes hemiplegia, paraplegia, and quadriplegia
Neuro 10 Includes peripheral and polyneuropathies
Respiratory 10 Includes respiratory disease
Skin 1 Includes cutaneous abscess, cellulitis, lymphangitis

Skin 3 Includes diseases of arteries, arterioles, & capillaries with ulceration & non-pressure, chronic
ulcers
Skin 4 Includes Stages Two through Four and Unstageable pressure ulcers
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PDGM - High Comorbidity Adjustment Interaction Subgroups

Comorbidity
Comorbidity Comorbidity
Subgroup Description Description
Subgroup Subgroup
Interaction
Behavioral 2 Includes diseases of arteries, arterioles, and capillaries with ulceration and non-
1 Includes depression and bipolar disorder Skin 3
pressure, chronic ulcers
Cerebral 4 Includes sequelae of cerebral vascular
2 Circulatory 4 Includes hypertensive chronic kidney disease
diseases
3 Heart 10 Includes cardiac dysrhythmias
diseases
4 Heart 11 Includes heart failure
diseases
5 Neuro 10 Includes peripheral and polyneuropathies
diseases
Includes hypertensive chronic kidney
6 Circulatory 4 Skin 1 Includes cutaneous abscess, cellulitis, lymphangitis
disease
Circulatory 4 Includes hypertensive chronic kidney Includes diseases of arteries, arterioles, and capillaries with ulceration and non-
7 Skin 3
disease pressure, chronic ulcers
Circulatory 4 Includes hypertensive chronic kidney
8 Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers
disease
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 and non-
12 Endocrine 3 Includes diabetes with complications Skin 3
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Comorbidity
Subgroup Subgroup
Interaction
Skin 4
13 Heart 10 Includes cardiac dysrhythmias Includes Stages Two Through Four and Unstageable Pressure ulcers
Neuro 10
14 Heart 11 Includes heart failure Includes peripheral and polyneuropathies
15 Heart 11 Includes heart failure Neuro 5 Includes Parkinson’s disease
16 Heart 11 Includes heart failure Skin 1 Includes cutaneous abscess, cellulitis, lymphangitis
17 Heart 11 Includes heart failure Skin 3
18 Heart 11 Includes heart failure Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers
19 Heart 12 Includes other heart diseases Skin 3
20 Heart 12 Includes other heart diseases Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers
21 Neuro 10 Includes peripheral and polyneuropathies Neuro 5 Includes Parkinson’s disease
22 Neuro 3 Includes dementias Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers
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Comorbidity
Subgroup Subgroup
Interaction
23 Neuro 5 Includes Parkinson’s disease Renal 3 Includes nephrogenic diabetes insipidus
Includes hemiplegia, paraplegia, and

24 Neuro 7 Renal 3 Includes nephrogenic diabetes insipidus
quadriplegia
Includes Chronic kidney disease and Includes diseases of arteries, arterioles, and capillaries with ulceration and non-
25 Renal 1 Skin 3
ESRD pressure, chronic ulcers
Includes Chronic kidney disease and

26 Renal 1 Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers
ESRD
27 Renal 3 Includes nephrogenic diabetes insipidus Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers
28 Resp 5 Includes COPD and asthma Skin 3
29 Resp 5 Includes COPD and asthma Skin 4 Includes Stages Two Through Four and Unstageable Pressure ulcers
Includes cutaneous abscess, cellulitis, Includes diseases of arteries, arterioles, and capillaries with ulceration and non-
30 Skin 1 Skin 3
lymphangitis pressure, chronic ulcers
Includes diseases of arteries, arterioles,

Includes Stages Two Through Four and Unstageable Pressure ulcers
31 Skin 3 and capillaries with ulceration and non- Skin 4
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Complex Scenarios
Let's Look At Some Scenarios & Apply What
We Already Know...
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Scenario # 1 – Physician Office Referral
•You receive a referral from the physician office for Mrs. W.
•The referral states the patient family phoned the MD office reporting she
fell at home yesterday and went to the emergency room and she is now
having difficulty walking.
•The physician requests the nurse make an evaluation to assess the
situation.
Question:
◦ Do you accept this referral?
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Scenario # 1 ‐ Possible Options...
A. Refuse to make the visit as the only diagnoses received are
unacceptable diagnoses
B. Make the visit and phone the physician with update of findings
C. Explain to the physician office that the diagnoses provided are
unacceptable diagnoses under PDGM and request additional
information including specific diagnosis information as to the
diagnosis that is causing the patient to have difficulty walking
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Scenario #1 ‐ Answer
A.Refuse to make the visit as the only diagnoses received are
unacceptable diagnoses
◦ This response may cause the physician to hesitate in giving the
agency additional referrals
B. Make the visit and phone the physician with update of findings
◦ This option could potentially negatively impact your agency. If
the physician does not have any additional diagnosis
information, the agency would not be able to bill for services
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C. Explain to the physician office that the diagnoses provided are
unacceptable diagnoses under PDGM and request additional
information including specific diagnosis information as to the
diagnosis that is causing the patient to have difficulty walking
 This would be the most appropriate response.
 The agency is explaining why the additional information
is needed, as well as ensuring that the clinician has
current diagnosis information to establish a plan of care
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Scenario #1 – Answer (continued)
•The HHA should have established processes for referrals that are
received without adequate diagnoses information.
•Consistent requests to physician/referral sources for needed
diagnosis information will help to improve diagnosis information
being received during the referral process
•Remember EVERY home health agency is requesting specific
diagnosis information
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Scenario #2 – Dr. Office Referral for PT
•Dr's office with a referral for physical therapy to see pt ‐ Ataxia. Patient
was seen by the Dr. yesterday.
•The office person who made the phone call does not have any additional
information but states she will fax the note from the office visit.
•The fax of the office note documents that the physician noted
increased ataxia due to her worsening Alzheimer's dementia and she is no
longer able to safely leave her home alone.
Question:
• How would you code this episode based on the information provided?
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•Primary Diagnosis ‐
◦ G30.9 Alzheimer's disease, unspecified
•Secondary Diagnoses ‐
◦ F02.80 Dementia in other diseases classified elsewhere without
behavioral disturbance
◦ R27.0 Ataxia, unspecified
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•In this scenario, Alzheimer's disease is coded primary as the
physician documented this is the reason for the patient's worsening
ataxia
•F02.80 Dementia is coded next following the etiology/manifestation
convention
•Ataxia, R27.0, is also coded as a secondary diagnosis, as ICD–10–CM
coding guidelines state that codes for signs and symptoms may be
reported in addition to a related definitive diagnosis when the sign
or symptom is not routinely associated with that diagnosis
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•In this scenario, the physician office note clearly states the
underlying diagnosis causing the patient's ataxia.
•Ensure when reporting to physician at end of admission assessment
that you inform that the primary diagnosis will be Alzheimer’s based
on his notes, coding guidelines and PDGM rules.
•If the visit note did not document a reason for the ataxia, you would
need to query the physician for further information.
•When querying the physician, be sure to document all
communication and confirmation of the diagnoses specified.
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Scenario #3 ‐ Physician referral –Patient
too sick to go to doctor’s office
•You receive a call from Dr. James, he is requesting you make an
evaluation visit to Mrs. V.
•The patient's family just called the physician office stating they think
she has the flu, but she is too sick to go to the Dr. Office to be seen.
Question:
• What should you do?
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Scenario #3 ‐Answer
• Initial Assessment –
 As this referral is “questionable” you can complete an
Initial Assessment to determine if the patient meets
eligibility criteria.
 Due to the COVID-19 PHE, as part of the 1135 waivers,
HHAs are permitted to perform Initial Assessments
remotely or by record review to determine the immediate
care and support needs of the patient and eligibility
including homebound status.
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•Lack of F2F documentation
◦ In the scenario, there is a lack of F2F documentation as the
patient has not seen the physician for the treatment/diagnosis of
the flu.
◦ If the patient fails to follow‐up with the physician for having the
flu, the agency would not receive payment as the patient would
not have had a F2F encounter for the reason for home health.
•Your Agency should consider policy for acceptance/non‐acceptance
of patients without current F2F encounter
◦ Accepting a patient without a current F2F puts the agency at risk
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•If agency decides to accept although there is no Face to Face, then what is the
patient’s home health primary diagnosis?
•This referral doesn’t have a specific disease or condition confirmed by the
physician.
•Therefore, this would not be an accepted referral for home health without the
physician giving more detailed information with an approved home health
primary diagnosis.
•For these reasons, best option is to not accept the patient.
•Use this as a teaching opportunity to the physician's office regarding what an
acceptable home health patient referral consists of in this era of HH (this was a
classic referral in the “Old Days” of HH).
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Scenario # 4 – Dr Office Referral with
Unacceptable Diagnosis
•Mr. X referred from MD office for PT for muscle weakness. Patient has DM, HTN.
•HH Intake RN contacts MD office nurse & states HH can no longer take primary
diagnosis of Muscle Weakness under PDGM. RN asks if the physician thinks that
primary diagnosis can be Muscle atrophy or wasting, as CMS has given as an
example.
•MD says patient doesn’t have Muscle atrophy, that is a different condition. He
says Mr. X is elderly, debilitated, prone to falls and needs PT for exercise for
strengthening.
•RN asks if agency can use DM as primary diagnosis and send an RN to see Mr. X.
•Physician says yes. States will change diagnosis on FTF.
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Scenario # 4 (continued)
•HHA admits patient with primary diagnosis DM‐ E11.9
•Comorbidity / secondary‐ Muscle Weakness, HTN, Fall history
Question:
• Does this scenario provide an acceptable solution under PDGM?
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Answer is NO
• Cannot “lead” the physician to put a primary diagnosis that isn’t
appropriate in order to admit a pt.
• Mr. X did not have any changed meds; BS stable at 110; no s/s
hyper/hypoglycemia, diet managed.
• So DM is not appropriate as a primary diagnosis. The clinical record will
not have any documentation showing justification for use of DM as
primary diagnosis.
• Result – if there is no acceptable diagnosis that is appropriate for Mr. X
primary diagnosis, reason for the home health encounter, then the
agency cannot admit Mr. X.
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Use of Z45.2
•Coders may assign Z45.2 (Encounter for adjustment and
management of vascular access device) as the principal diagnosis or
the first listed secondary diagnosis code in order to be placed in the
Complex Nursing Interventions clinical group.
•If the agency is ONLY doing care of vascular access device and no
other care being provided, then Z45.2 can be assigned as the
primary diagnosis.
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Use of Z45.2
•In a case where the patient is receiving an IV antibiotic for sepsis,
per coding guidelines sepsis should be coded as the primary
diagnosis
•CMS instruction is if the IV is not the primary reason the patient
requires home health care, but where there may be some sort of
intervention noted on the home health plan of care, then it would be
appropriate to report Z45.2 (but not as the principal or first
secondary diagnosis)
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Scenario #5 ‐ Sepsis, IV antibiotics
•You receive a referral from the hospital for Mr. N, who was admitted
with sepsis, UTI due to E Coli.
•Pt had PICC line placed and is being discharged home with IV
antibiotics for 5 additional days.
Question:
• How could you code this patient?
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Primary Diagnosis ‐
◦ A41.51 Sepsis due to Escherichia coli
• Clinical Group‐ MMTA Infection
Secondary Diagnoses –
◦ N39.0 Urinary tract infection, site not specified
◦ Z45.2 Encounter for adjustment and management of vascular
access device
◦ Z79.2 Long term (current) use of antibiotics
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Primary Diagnosis –
◦ A41.51 Sepsis due to Escherichia coli
• Clinical Group‐ Complex Nursing Interventions
◦ Z45.2 Encounter for adjustment and management of vascular
access device
◦ N39.0 Urinary tract infection, site not specified
◦ Z79.2 Long term (current) use of antibiotics
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Scenario # 6 ‐ Change in 30‐day
•Mrs. J admitted for post op abdominal surg wound care. Has DM and COPD.
•Primary Diagnosis ‐ Z48.01 Encounter for change or removal of surgical wound dressing.
Clinical Group‐ Wound
•Goal for POC is wound to heal in 3 weeks.
•Goals and interventions on POC for Wound care 3 x week as well as DM and COPD.
•Week 4 wound is healed. However, blood sugars have been over parameters. Pt not
following ADA diet. MD orders new meds and dietician.
•Wound healing is what was planned at SOC.
•Patient not discharged, however, as DM requires interventions, education, & visits
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Scenario # 6 ‐ Change in 30‐Day
(continued)
•Day 28 visit, patient still has elevated blood sugar, physician requests continued visits.
•2nd 30 day – will have a new primary diagnosis of DM. Physician’s order obtained for
primary diagnosis change. Primary Diagnosis of DM‐ E11.9, put on the claim, to change
the clinical grouping to MMTA‐ Endocrine.
•Follow up OASIS not done for SCIC / change in primary diagnosis because wound healing
was expected on POC. And DM was already being cared for on POC interventions and
goals.
•CMS did not make it mandatory for OASIS follow up to be done for diagnosis changes at
2nd 30‐day period; it is up to agency to decide if OASIS follow will be done or not.
•Per CoP’s, 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.
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Scenario # 6 ‐ 30‐Day Change
•Patient admitted with exacerbation COPD J44.1 Chronic obstructive pulmonary
disease with (acute) exacerbation, Clinical Group MMTA ‐ Respiratory
•Patient falls day 25 – ER, injury‐severe laceration lower leg, no hospitalization
•OASIS RFA #5 follow‐up other completed by RN.
•Physical therapy ordered, RN to do wound care daily x 7, then 3 x week.
•2ND 30 DAY
◦ Primary diagnosis changed to laceration left leg‐ S81.812D ‐ Clinical Group
Wound‐ as this is the diagnosis requiring the most intensive services
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Scenario # 7 – Primary Diagnosis Effects
on Comorbidity Adjustment
◦ Referral 1:
• Pt with diagnosis of exacerbation diastolic CHF, also has
HTN and stage 2 pressure ulcer to coccyx.
 MD has ordered SN visits 3 x week to monitor cardiac status,
response to med changes, wound care is 2 x week
• Primary I11.0, Secondary- I50.31 & L89.152 – results in a
high comorbidity adjustment- Comorbidity Subgroup
interaction #18 Heart 11 and Skin 4
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Scenario # 8 – Primary Diagnosis Effects
on Comorbidity Adjustment
Referral 2:
• Pt with diagnosis of stage 2 pressure ulcer to coccyx, also has
Dx of HTN and CHF.
• MD ordered SN visits 2 x week for wound care.
Primary L89.152, Secondary- I11.0 & I50.9- results in a low
comorbidity adjustment- Both I11.0 & I50.9 are in the
comorbidity subgroup Heart 11
***Primary diagnosis is not factored into the comorbidity
adjustment
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Scenario # 9 – Missing Discharge
Summary
◦ Referral Scenario 1: Mrs. Z referred to HH for post op care after having
gallbladder removed
◦ Only information given is that patient is debilitated, weak, has difficulty
walking and lives alone.
◦ HHA admits and codes : Z48.815 Encounter for surgical aftercare
following surgery on the digestive system
◦ Clinical group : MMTA Surgical Aftercare
◦ Comorbidity – None ‐No secondary diagnoses are in the comorbidity
groups for low or high
• R53.81 Debility
• R53.1 Weakness
• R26.2 Difficulty Walking
• Z60.2 Lives Alone
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Scenario # 9 –No Comorbidity Coding
Scenario – First 30‐Day Period
This scenario based on:
• Admission Source – Institutional
• Timing – Early
• Clinical Group – MMTA Surgical Aftercare
• Functional Impairment Level – High
• Comorbidity Adjustment – None
HIPPS of 2GC11, case mix weight of 1.4027, LUPA threshold of 5, and
payment of $2,254.53
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Scenario # 9 – Missing Discharge
Summary
Referral Scenario 2: Mrs. Z referred to HH for post op care after having
gallbladder removed. In the hospital EMR, there is documentation in
Discharge summary that patient has these diagnoses: HTN, CHF, COPD
◦ HHA admits and codes : Z48.815 Encounter for surgical aftercare
following surgery on the digestive system
◦ Comorbidity – Low
• I11.0 Hypertensive heart disease w/heart failure
• I50.9 Heart Failure unspecified • R53.1 Weakness
• J44.9 COPD unspecified • R26.2 Difficulty Walking
• R53.81 Debility • Z60.2 Lives Alone
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Scenario # 9 –Low Comorbidity Coding
• Comorbidity Adjustment – Low
◦ I11.0 Hypertensive heart disease w/heart failure & I50.9 Heart failure
unspecified are both in the low comorbidity subgroup Heart 11
HIPPS of 2GC21, case mix weight of 1.4535, LUPA threshold of 5, and payment
of $2336.18
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Scenario # 9 – Additional Clinical
Information Confirmed at SOC Visit
Referral Scenario 3: Mrs. Z referred to HH for post op care after
having gallbladder removed. In the hospital EMR, there is
documentation in Discharge summary that patient has HTN, CHF,
COPD. During the SOC visit, the SN notes that the patient has a
wound on her left ankle.
• RN calls the PCP‐ confirms that the patient has a chronic stasis
ulcer due to venous insufficiency and receives orders for wound
care to be done 2 x week.
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Scenario # 9 – Additional Clinical Information
Confirmed at SOC Visit (continued)
◦ Referral scenario 3
◦ HHA admits and codes : Z48.815 Encounter for surgical aftercare following surgery on the
digestive system
◦ Comorbidity – High
• I87.2 Venous insufficiency (chronic) (peripheral)
• L97.322 Non‐pressure ulcer of left ankle w/fat layer exposed
• I11.0 Hypertensive heart disease with heart failure
• I50.9 Heart Failure unspecified • R53.1 Weakness
• J44.9 COPD unspecified • R26.2 Difficulty Walking
• R53.81 Debility • Z60.2 Lives Alone
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Scenario # 9 –High Comorbidity – Coding
◦ Comorbidity Subgroup Interaction # 17 –
• L97.322 Non‐pressure ulcer of left ankle w/fat layer exposed‐ comorbidity
subgroup Skin 3,
• I11.0 Hypertensive heart disease with heart failure, I50.9 Heart failure unspecified‐
both comorbidity subgroup Heart 11
◦ Comorbidity Subgroup Interaction # 28 –
• L97.322 Non‐pressure ulcer of left ankle w/fat layer exposed‐comorbidity
subgroup Skin 3
• J44.9 COPD unspecified‐comorbidity subgroup Resp 5
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Scenario # 9 –High Comorbidity Coding
• Comorbidity Adjustment – High
HIPPS of 2GC31, case mix weight of 1.5501, LUPA threshold of 5, and
payment of $2491.44
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Scenario # 10 – Coding Sequencing
•Referral from hospital for Mr. C, who has been hospitalized for 2 weeks. He was initially
admitted for amputation of his left great toe due to diabetic ulcer with gangrene.
•He subsequently developed a UTI which was treated with IV abx and has resolved.
•He was also noted to have AKI, hypokalemia, and hyponatremia which were treated and
have resolved.
•He has a history of PVD, HTN, CHF, CKD 3, Atrial Fib, h/o prostate cancer, BPH, urinary
incontinence, and he lives alone.
•The surgical amputation site is healing well. The physician has ordered SN for wound
care to surgical site 2 x week and PT 3 x week for evaluation, gait training and safety
How would you code this patient?
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•You would not code DM ulcer with gangrene as the ulcer and
gangrene were resolved by the amputation
•You would not code the UTI, AKI, hypokalemia or hyponatremia as
they are resolved
•You would code the patient’s pertinent medical diagnosis that may
affect the POC
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• Z47.81 Encounter for orthopedic aftercare following surgical • I48.91 Unspecified Atrial Fib
amputation • N40.1 Benign prostatic hyperplasia with lower
• Z89.412 Acquired absence of left great toe urinary tract symptoms
• E11.51 Type 2 DM with diabetic peripheral angiopathy without • R32 Unspecified urinary incontinence
gangrene
• Z60.2 Problems related to living alone
• E11.22 Type 2 DM with diabetic chronic kidney disease • Z86.31 h/o diabetic ulcer
• I13.0 Hypertensive heart and chronic kidney disease with heart • Z87.440 Personal history of UTI
failure and stage 1‐4 CKD
• Z85.46 Personal history of malignant neoplasm of
• I50.9 Heart failure unspecified
prostate
• N18.30 Chronic kidney disease, stage 3 unspecified • Z79.01 Current (long term) use of anticoagulant
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Scenario # 10 –Low Comorbidity –
Coding Scenario – First 30‐Day Period
◦ I13.0 is in comorbidity subgroup Circulatory 4
◦ I50.9 is in subgroup Heart 11
◦ DM diagnoses are in group Endocrine 3 which is not in one of the 14 low
comorbidity subgroups
◦ A fib is in group Heart 10 which is not in one of the 14 low comorbidity
subgroups
◦ BPH is in group Renal 3 which is not in one of the 14 low comorbidity
subgroups
◦ None of the Z codes are in a comorbidity subgroup
◦ This combination of diagnoses does not have any Comorbidity Subgroup
Interactions, therefore no High Comorbidity adjustment
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Scenario # 10 –Low Comorbidity –
Coding Scenario – First 30‐Day Period
• Clinical Group –MS Rehab
• Comorbidity Adjustment – Low
HIPPS of 2EC21, case mix weight of 1.5773, LUPA threshold of 6, and
payment of $2535.16
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Scenario # 11 – COVID‐19
•Referral from hospital for Mr. A, an 80‐year‐old male who was
admitted to the hospital with symptoms of cough, fever, and
weakness for the past week.
•He is diagnosed COVID 19 and has a history of HTN and CAD.
•He is discharged home after 3 weeks in the hospital with orders for
PT for treatment of weakness with difficulty ambulating.
•The physician documents COVID‐19 and weakness on the F2F.
•How would you code this patient?
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Scenario # 11 – COVID‐19 ‐ Coding

• U07.1 COVID ‐19
• R53.1 Weakness
• R26.2 Difficulty ambulating
• I25.10 Atherosclerotic heart disease of native coronary artery without angina
pectoris
• I10 Essential (primary) hypertension
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Scenario # 11 – COVID‐19 ‐ Rationale

Rationale‐
•In this scenario, even though it has been 3 weeks since the patient tested
positive for COVID, there has not been a follow up test done and the physician
has not documented that the patient no longer has COVID. There is no specific
timeframe for considering a COVID diagnosis as current vs history. Coding is
based on the physician documentation.
•As the physician has documented COVID 19 with weakness and difficulty
ambulating on the F2F, per the guidelines U07.1 is coded primary with symptom
codes of R53.1 weakness and R26.2 difficulty ambulating are coded as
additional diagnoses. Codes for signs and symptoms may be reported in
addition to a related definitive diagnosis when the sign or symptom is not
routinely associated with that diagnosis.
•I10 and I25.10 are coded as they are comorbidities.
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Situations similar to this are a commonly seen in home health.
You must query the physician if there are any concerns related to COVID being a
current diagnosis and for symptom codes received without a current COVID
diagnosis.
COVID‐19 is a significant public health issue, and for some people there can be long
term effects following infection.
These can range from symptoms such as loss of smell or taste, or can include chronic
respiratory failure, in some cases particularly following COVID‐19 pneumonia or
Acute Respiratory Distress Syndrome (ARDS).
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WHO has added a new code to ICD‐10 at U09.9, for Post COVID‐19 condition,
unspecified.
At the March 2021 ICD‐10 Coordination & Maintenance Committee Meeting it was
proposed to add this code in ICD‐10‐CM and the implementation date was expected
to be October 1, 2021.
However, April 27, 2021, CMS released the FY 2022 Hospital IPPS proposed rule
which includes the proposed 2022 ICD‐10 codes, but U09.9 Post COVID‐19 condition
was not one of the proposed codes.
You can submit comments on this regulation until June 28, 2021 –
http://www.regulations.gov
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 Referral from hospital for Mr. J, patient with a diagnoses of
COVID-19 with pneumonia. He also has diagnoses of
emphysema and COPD due to smoking. He is discharged home to
continue with antibiotics for the pneumonia and continuous oxygen
which is not new.
• How would you code this patient?
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• U07.1 COVID –19
• J12.82 Pneumonia due to coronavirus disease 2019
• J43.9 Emphysema
• F17.218 Nicotine dependence, cigarettes, with
other nicotine induced disorders
• Z99.81 Dependence on supplemental oxygen
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Rationale-
 The COVID-19 is coded as primary with all the manifestations of
the COVID-19 following, therefore J12.82 Pneumonia due to coronavirus
disease 2019 is coded next.
 J43.9 Emphysema unspecified is coded as the guidelines state when
COPD unspecified and emphysema are both documented by the
provider, emphysema is coded.
 The nicotine dependence with other induced disorders is coded because
the emphysema and COPD are documented as related to the smoking.
 The oxygen is an important part of the plan of care so is also coded.
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 Referral from hospital for Mrs. Z, who was hospitalized for
COVID 19 with pneumonia and acute respiratory failure
complicated by a 15-year history of COPD which
was exacerbated.
 She recovered and went to rehab for four weeks for strengthening.
 Prior to discharge home the patient tested negative for COVID 19.
• How would you code this patient?
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• J44.1 COPD exacerbation
• Z86.16 Personal history of COVID‐19
• Z87.01 Personal history of pneumonia
• Z99.81 Dependence on supplemental oxygen
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Rationale-
 The COPD was exacerbated and is the focus of care so is
coded as primary.
 The patient now tests negative for the COVID-19 virus, so the
history code is used.
• FY2021 Coding Guidance "Personal history of COVID-19 - For patients
with a history of COVID-19, assign code Z86.16, Personal history of
COVID-19. "
 The pneumonia is resolved so history is coded.
 Oxygen use is also coded.
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Scenario # 14 ‐ COVID‐19
Patient was admitted to hospital 2 weeks ago with a diagnosis of
COVID-19. The patient now tests negative for COVID-19, however the
physician has documented the patient has multisystem inflammatory
syndrome as a sequelae of COVID-19.
How would you code this patient?
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Primary Diagnosis -
• M35.81 (Multisystem inflammatory syndrome)
Secondary Diagnosis -
• B94.8 (Sequelae of other specified infectious and parasitic
diseases)
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Rationale -
Per the coding guidelines “If MIS develops as a result of a previous
COVID19 infection, assign codes M35.81 (Multisystem inflammatory
syndrome) and B94.8 (Sequelae of other specified infectious and
parasitic diseases).”
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Scenario # 15 – COVID ‐19
78‐year‐old patient with history of CHF, HTN, and mild intermittent asthma, presented
to the hospital six days ago, complaining of developing cough two days prior and upon
presentation having chills, fatigue, and becoming notably more SOB. Patient was found
to be hypoxic with pulse ox of 87%; rapid test was positive for COVID‐
19, and CXR showed bilateral ground glass opacites. Patient was admitted
with COVID Pneumonia. Pt was started on oxygen, received Remdesivir x 5 days and
Dexamethasone.
Patient’s respiratory status stabilized, and he is being discharged home today on
oxygen, decreasing doses of oral prednisone, with SN ordered for respiratory
assessment, medication and disease process teaching.
How would you code this patient?
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Scenario # 15 – COVID ‐19 ‐ Answer

Primary ‐
• U07.1 (COVID‐19)
Secondary –
• J12.82 (Pneumonia due to coronavirus disease 2019)
• I11.0 (Hypertensive heart disease with heart failure)
• I50.9 (Heart failure, unspecified)
• J45.20 (Mild intermittent asthma, uncomplicated)
• Z99.81 (Dependence on supplemental oxygen)
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Scenario # 15 – COVID ‐19 ‐ Rationale

COVID‐19 is coded primary as per the guidelines – “When the reason for the
encounter/admission is a respiratory manifestation of COVID‐19, assign code U07.1
(COVID‐19) as the principal/first‐listed diagnosis and assign code(s) for the
respiratory manifestation(s) as additional diagnoses.
New code for pneumonia due to COVID‐19 as of Jan 1 — J12.82 is the first secondary
diagnosis.
I11.0 is coded next, followed by
I50.9 unspecified as there was no additional
documentation of the type of heart failure
J45.20 is coded next followed by Z99.81 as the patient was d/c home on oxygen.
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Scenario # 15 – COVID ‐19
Four weeks later, the same patient returns to the ER reporting sudden onset of
SOB, chest pain and palpitations. D dimer was elevated, and V/Q scan revealed
a Pulmonary embolism. A repeat COVID‐19 test was negative, and the
physician diagnosed the patient with PE due to recent history of COVID‐19. The
patient was discharged on Warfarin and the nurse is to obtain INR in three
days, and patient is to continue home oxygen.
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Scenario # 15 – COVID ‐19 ‐ Answer

Primary
• I26.99 (Other pulmonary embolism without acute cor pulmonale)
Secondary
• B94.8 (Sequelae of COVID‐19)
• I11.0 (Hypertensive heart disease with heart failure)
• I50.9 (Heart failure, unspecified)
• J45.20 (Mild intermittent asthma, uncomplicated)
• Z51.81 (Encounter for therapeutic drug level monitoring)
• Z79.01 (Long term (current) use of anticoagulants)
• Z99.81 (Dependence on supplemental oxygen)
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Scenario # 15 – COVID ‐19 ‐ Rationale

I26.99 is coded primary as per the physician documentation the PE is a
result of a recent COVID‐19 infection, which is followed
by B94.8 (Sequelae of other specified infectious and parasitic diseases).
I11.0, I50.9, J45.20 are comorbidities that may affect the patient and are
coded.
Z51.81 is coded as the nurse is to obtain an INR and there is a code also
note at Z51.81 that states to code also any long‐term (current) drug
therapy, therefore Z79.01 is also coded.
Z99.81 is coded as the patient is to continue home oxygen.
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Scenario # 16 ‐ Vaping
19‐year‐old patient was admitted to hospital with acute respiratory
distress syndrome, abdominal pain and diarrhea secondary to e‐cigarette
use/vaping.
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Scenario # 16 ‐ Vaping ‐ Answer

Primary
• U07.0 Vaping‐related disorder
Secondary
• J80 Acute respiratory distress syndrome
• R10.84 Generalized abdominal pain
• R19.7 Diarrhea, unspecified
• F17.298 Nicotine dependence, other tobacco product, with other nicotine‐
induced disorders
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Scenario # 16 ‐ Vaping ‐ Rationale

U07.0 is coded primary as the guidance states when patients present
with conditions related to vaping, assign code U07.0 as the principal
diagnosis.
The guidance states to assign additional codes for other manifestations,
so J80, R10.84, R19.7 are also coded
As the patient uses an e‐cigarette F17.298 is also coded
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Education
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Intake
•Must ensure that intake process is such that No Unacceptable
Diagnoses will go through to admission
Admitting Clinician‐
• Ensure thorough knowledge of acceptable diagnosis, skilled need
• Diagnosis specifics
• When and how to Query physicians
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Coding Department
•If unaccepted diagnosis, send immediately back to clinical manager.
•Clinical manager addresses for this patient, but also uses to educate and
tighten processes to prevent this from occurring.
•Coding ensures all secondary diagnosis that may affect the POC are coded
to the highest level of specificity.
•Coder has access to grouper tool in order to see the clinical group, low or
high comorbidity adjustment.
•Some EMRs have "grouper like" functionality within their software that
can identify clinical groups, low/high comorbidity, functional impairment
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Conclusion
•PDGM requires HHA’s to ensure that patients are appropriate to be
admitted to Home Health by having an Acceptable Primary Diagnosis
•If physician doesn’t provide an underlying cause for an unacceptable
diagnosis and there are no other appropriate diagnoses for home health,
then may not be able to accept a pt.
•Code to highest specificity!
•Code to Coding Guidelines, Physician documentation & Comprehensive
Assess
•Many Scenarios under PDGM you will find patient by patient!
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Thank You
For Participating!
info@healthcareprovidersolutions.com
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Challenging PDGM Coding Scenarios

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Challenging PDGM Coding Scenarios

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6/3/2021

Presenter: Sharon M. Litwin RN, BSHS, MHA, HCS-D

UNDERSTAND COMPLEX INTAKE AND REVIEW INTAKE AND CODING DISCUSS ACTION PLANS/BEST

PDGM Clinical Groups

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 Aftercare and Skin/

Medication Management, Teaching and Assessment (MMTA)

MMTA – Infectious Disease/Neoplasms/ Blood-

PDGM -Low Comorbidity Adjustment Subgroups

Circulatory 9 Includes acute and chronic embolisms and thrombosis

Circulatory 10 Includes varicose veins with ulceration

Respiratory 10 Includes respiratory disease

Skin 1 Includes cutaneous abscess, cellulitis, lymphangitis

PDGM - High Comorbidity Adjustment Interaction Subgroups

PDGM - High Comorbidity Adjustment Interaction Subgroups

15 Heart 11 Includes heart failure Neuro 5 Includes Parkinson’s disease

21 Neuro 10 Includes peripheral and polyneuropathies Neuro 5 Includes Parkinson’s disease

PDGM - High Comorbidity Adjustment Interaction Subgroups

23 Neuro 5 Includes Parkinson’s disease Renal 3 Includes nephrogenic diabetes insipidus

Includes hemiplegia, paraplegia, and

Includes Chronic kidney disease and

Includes diseases of arteries, arterioles,

Scenario # 11 – COVID‐19 ‐ Coding

Scenario # 11 – COVID‐19 ‐ Rationale

Scenario # 12 – COVID‐19 ‐ Coding

Scenario # 12 – COVID‐19 ‐ Rationale

Scenario # 13 – COVID‐19 ‐ Coding

Scenario # 13 – COVID‐19 ‐ Rationale

How would you code this patient?

Scenario # 15 – COVID ‐19 ‐ Answer

Scenario # 15 – COVID ‐19 ‐ Rationale

Scenario # 15 – COVID ‐19 ‐ Answer

Scenario # 15 – COVID ‐19 ‐ Rationale

Scenario # 16 ‐ Vaping ‐ Answer

Scenario # 16 ‐ Vaping ‐ Rationale

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