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Billing and Coding Checklist to Maximize Revenue

Medical coding bridges the connection between providers and payers with a universal set of codes for all diagnoses, procedures, services and equipment.

Coding directly affects revenue generated for an episode. There are several factors to consider to capture the precise clinical conditions and comorbidities of the patient.

Medical Coding Checklist

Use this coding checklist to maximize your revenue:

1. Face-to-Face Documents

  • Information must be based on the physician’s and facility’s medical records.
  • Appropriate documents include:
    • Discharge summary
    • Progress note from the facility or physician
    • Clinical summary
    • Admission summary
    • Medical history
    • Physical assessment
  • Submitting the diagnosis list, recent procedures and injuries alone will not suffice.
  • Active conditions indicated in the documents must be included, as well as any relevant medical or surgical history.

2. Primary Coding

  • The primary code must be geared toward the patient’s focus of care.
  • Primary codes under certain complex clinical groupings have higher reimbursement amounts, such as:
    • Neuro and musculoskeletal rehab
    • Wounds
    • Complex nursing interventions
    • Surgical aftercare

3. Specific Coding and Laterality

  • Diagnosis codes are to be used and reported at their highest number of characters available. ICD-10-CM diagnosis codes are composed of three to seven characters.
  • Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by including more characters, which provide greater detail.
  • A three-character code is only to be used if it is not further subdivided.
  • A code is invalid if it does not meet the full number of characters required for that diagnosis, including the seventh character, if applicable.
  • Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided, and the condition is bilateral, assign separate codes for both the left and right side.

4. Combination Codes

  • A combination code is a single code used to classify two diagnoses, a diagnosis with an associated secondary process (manifestation) or a diagnosis with an associated complication.
    • When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code.
  • Common combination codes include:
    • Hypertension
    • Diabetes mellitus
    • Chronic kidney disease
    • Heart diseases
    • Heart failure

5. Diagnoses Sequencing and Comorbidity Adjustment

  • Coding guidelines must be used for conditions when indicated to specify the etiology first or to use additional codes.
  • Code all documented conditions that coexist at the time of the encounter and require or affect patient care.
  • Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
  • If a patient has comorbidities that need a higher level of care and higher resource use, this will affect the comorbidity adjustment, resulting in a higher revenue.

Pair this checklist with an intuitive home health software that prioritizes accurate claims through automatic coding features, and your home health organization will never miss out on reimbursement opportunities.

For more in-depth coding help, register for the Improve Home Health Outcomes With Coding Updates webinar.

Axxess Home Health, a cloud-based home health software, provides additional support through a Patient-Driven Groupings Model (PDGM) resource page, with recent coding changes, tips to minimize Low Utilization Payment Adjustments (LUPAs) and other tools for success.


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