Note: This article first appeared in DecisionHealth Daily. Click here to subscribe for free.

The Association of Home Care Coding and Compliance (AHCC) has voiced concerns over M1024 restrictions outlined in the proposed PPS annual rate update.  If the proposed rule is adopted in its entirety, it could mean a significant decrease in clinical points for agencies. 

Currently, M1024 is completed if a fracture or a resolved condition has been replaced by a V code in the primary or secondary position and if a V code listed primary has replaced a code from Diabetes, Skin 1 or the Neuro 1 category.

CMS is proposing enhancements to the Grouper Logic to Restrict M1024 to permit fracture diagnoses codes only, which according to ICD-9-CM coding guidelines cannot be reported in a home health setting as a primary or secondary diagnosis. CMS will pair the fracture codes (V-code) with appropriate diagnosis codes and will award points only when these pairings appear in the primary and payment diagnosis fields.

CMS has also proposed a revision in the Grouper Logic to permit equivalent scoring when the Diabetes, Skin 1, or Neuro 1 codes are submitted immediately following the V-code in the M1020 position without requiring utilization of the payment diagnosis field.

According to CMS, these Grouper enhancements will enforce appropriate use of the payment diagnosis field based upon the guidance issued in Attachment D, putting CMS in a much more favorable position to eventually retire the payment diagnosis field (M1024).

The Association of Home Health Coding and Compliance points out that the proposal to restrict the use of M1024 to only permit fracture diagnoses codes if paired with a fracture (V-code) appearing in the primary (M1020) and payment diagnosis fields (M1024) is not representative of all the sequencing requirements for fracture aftercare. Diagnoses are sequenced according to the seriousness of the patient’s condition. Some encounters include ‘aftercare for a fracture’ as a secondary diagnosis because the fracture does not meet eligibility as the primary reason for admission. 

In addition, AHCC explains that home health, by definition, delivers subsequent care. Many times, the reason for admission is to provide aftercare for a resolved condition. CMS’s own instructions from Attachment D indicated that V-code reporting on the OASIS was required in October 2003 in compliance with HIPAA. In that same document, the payment field OASIS question was designed and introduced to provide a payment vehicle for diagnoses that no longer could be reported in the primary or secondary positions because of HIPAA requirements.

According to AHCC, many case mix diagnoses are resolved prior to home health admission but represent the primary reason for the encounter. Restricting M1024 only to fracture codes would represent an unfair burden to home health, since the majority of case mix codes listed in M1024 represent resolved conditions affecting the home health plan of care.

These proposed restrictions are significant and The Advocacy group is drafting a set of detailed comments addressing the Home Health industry’s concerns and will be sending them to CMS during the official comment period. They encourage their members to comment on the rule; the comment period ends September 4.

Tricia A. Twombly, BSN, RN HCS-D, HCS-O, COS-C, CHCE, AHIMA approved ICD-10-CM trainer, is a DecisionHealth Senior Director with over 25 years of home care experience. She also serves as Editor for DecisionHealth's ICD-9 and ICD-10 coding manuals and technical reviewer for both the Diagnosis Coding Pro for Home Health and the Board of Medical Specialty Coding & Compliance online education courses. She is presenting at DecisionHealth's Home Health Coding Summit this week in Chicago.