Home Health Coding Advanced Topics

PDGM Deep Dive

Five PDGM Classification Factors

1.Timing: Early (1st 30-day period) vs Late (2nd+ periods) — early pays more

2.Admission source: Community (higher payment) vs Institutional (post-hospital)

3.Clinical grouping: 12 groups based on primary diagnosis code

4.Functional level: Low/Medium/High from OASIS functional items (ambulation, transfers, ADLs)

5.Comorbidity adjustment: None/Low/High from secondary diagnoses

Clinical Groupings (12 Groups)

•Musculoskeletal Rehab | Neuro/Stroke Rehab | Wound Care

•Complex Medical/Surgical | Respiratory | Endocrine

•Infectious Disease/Neoplasms | Cardiac/Circulatory | MMTA (Medication Mgmt)

•Behavioural Health | Immobility | GI/GU

Low Utilization Payment Adjustment (LUPA)

•If visits fall below LUPA threshold per 30-day period, payment switches to per-visit rate

•Thresholds vary by clinical group (2-6 visits)

•LUPA significantly reduces payment — avoid unnecessary LUPAs

Complex Coding Scenarios

CVA/Stroke in Home Health

•Acute CVA (I60-I63): NEVER coded in home health — acute hospital setting only

•Post-CVA home health: use I69.x sequela codes

•I69.3-: Following cerebral infarction

•I69.1-: Following non-traumatic subarachnoid hemorrhage

•I69.2-: Following intracerebral hemorrhage

•Code specific residuals: hemiplegia (I69.35x), aphasia (I69.32x), dysphagia (I69.39x)

•7th character for laterality and dominance in I69.35x codes

Wound Coding 7th Character Rules

•A (Initial encounter): Active treatment — wound VAC, antibiotics for infection

•D (Subsequent): Routine care during normal healing — no active treatment

•S (Sequela): Late effect after acute phase

•Key: Wound VAC presence changes D → A even if wound is healing

Diabetes and Wounds

E11.621  T2DM with foot ulcer (left foot)
L97.412  Non-pressure chronic ulcer, left heel, fat layer exposed
Z79.4    Long-term insulin use (if applicable)

Never code E11.9 (unspecified DM) when wound present — specificity required for PDGM comorbidity.

Home Health Compliance

OIG Focus Areas for Home Health

•Homebound status documentation: most common audit finding

•Physician oversight: timely 485 certifications and signatures

•Therapy necessity: documentation supporting skilled therapy need

•Duplicate billing: same patient billed by multiple agencies

Documentation Audit Trail

Every visit note must independently support:

•Skilled need for THAT visit (not just "see care plan")

•Specific skilled interventions performed

•Patient's response and progress toward goals

•Ongoing need for skilled services

•Homebound status indicators

Coding for Common HH Conditions

Wound Categories

Code	Type	Example

|------|------|---------|

L89.x	Pressure ulcer	Sacral stage 3
L97.x	Non-pressure lower limb	Diabetic foot
T81.x	Post-procedural	Surgical wound dehiscence
I83.x	Varicose veins with ulcer	Venous stasis

HTN Combination Codes

Combination	Code

|-------------|------|

HTN + HF only	I11.0 (with HF)
HTN + CKD 1-4	I12.9
HTN + CKD 5/ESRD	I12.0
HTN + HF + CKD 1-4	I13.0
HTN + HF + ESRD	I13.11

Home Health Coding — Advanced