Decoding PDGM’s Questionable Encounter Codes


The home health Industry’s coming payment reform, the Patient-Driven Groupings Model or PDGM, has exposed a common deficit: correct use of the ICD-10-CM code set’s Official Guidelines and Conventions. When the 2019 Home Health Prospective Payment System (HHPPS) Final Rule was published late last year, CMS pointed out that 15 percent of the 30-day payment periods analyzed were classified as “questionable encounters.”  In these episodes of care, the primary diagnoses coded as the primary reason for home health care were unspecified or symptom codes.

The Correct Way to Code

According to the Official Guidelines and Conventions for the ICD-10-CM code set, a coder is to code a disease process to the highest level of known specificity. Furthermore, these rules state that symptom codes are to be used only when a diagnosis is not yet known, or when the code set requires an additional symptom code only. Otherwise, if a symptom is inherent to a disease process, the underlying disease process is to be coded rather than the symptom.

For example, if the patient has generalized muscle weakness due to inactivity as a result of COPD, then COPD is to be coded. The muscle weakness would be reflected by documentation such as manual muscle testing scores, functional assessment findings, and observations noted in the narrative notes.

For several years agencies have been assigning symptom codes, especially those related to mobility issues, such as gait abnormalities or difficulty walking, as a way to “justify” therapy utilization. However, the documentation of baseline functional status and ongoing progress to successful outcomes is the basis on which services are justified rather than improperly coding symptoms codes. Another widespread issue is the use of unspecified codes, which are often used because of a lack of information from the referring provider or institution.

According to the information available at this time on PDGM, there are tens of thousands of diagnosis codes that are either symptom codes or so obviously unspecified that they are deemed inappropriate as a primary reason for home care diagnoses. For these, when used as primary diagnosis, PDGM the payment system will not calculate a payment and the bill will return to the provider (RTP) for correction.

How Agencies Can Prepare

Home health agencies should begin now to firm up processes to prepare for PDGM. By refining the referral intake, documentation, quality assurance and coding process, agencies can lessen the likely impact to cash flow that improper coding will have in the new payment system. Agency staff and providers who frequently refer patients should be educated on the impact of PDGM.

Referral intake is an ideal first step for implementation of improved processes. When receiving a potential referral, adequate information should be received to ensure that the patient meets the criteria to receive the Medicare Home Health Benefit. This includes information required for payment, such as the face-to-face encounter, certification information, history and physical, consultation notes, progress notes, discharge summary and list of medications and diagnoses.

If any part of needed documentation is missing, these should be requested immediately, rather than when reviewing the documentation after admission has occurred. If the information received does not give specific enough diagnoses, ask the provider for additional insights and more specific diagnoses.

Proper diagnosis coding is imperative in PDGM. Using a code on the unacceptable primary diagnosis codes list will result in delayed claims, corrections, and cash flow interruptions. Agencies should ensure they have properly credentialed coders or partnerships with professional coders. Audits of agency data should be performed to determine the number of questionable encounter codes are routinely used, and steps to ensure that more accurate information is obtained in the future.

These steps, in conjunction with clinician education regarding appropriate patient-specific documentation, will establish best practices now and success in the coming months of a new payment system.

Axxess is a partner you can trust on the journey to PDGM success. Our PDGM resource center features answers to other frequently asked questions, quick reference guides, and videos to help providers prepare for, navigate, and thrive in this changing environment. One of our quick reference guide explains the top 25 questionable encounter codes so that agencies can spot what has changed and adjust as needed.