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Place diagnoses in M1010 when treatment goes beyond standard medications
CMS has given guidance on when to list inpatient diagnoses, M1010, and the agency specifically answers the question of whether giving medicines is “active treatment.” Question: If a patient is...
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Cough. Wheeze. Now how do we code that respiratory problem?
There is always so much confusion on respiratory codes … here is a quick guide on when to use them. 496, COPD NEC This umbrella term means there are no exacerbations or contributing diseases. 491.20:...
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SOC dates, SOC for OASIS … how do they work, again?
I get timing questions all the time regarding SOC. Here is a recent one that should help other agencies tweak their processes or know that they’re on steady ground with CMS. Question: Our staff are...
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Being on antidepressants doesn’t mean a patient is depressed
If your patient show signs of depression during the Start of Care visit, and the patient is on antidepressants, can depression (311) be included? Not without a specific diagnosis from the ordering...
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836 codes are case-mix
I’ve received some queries in the past few days wondering if the 836 codes are case-mix. They are! Your books are right! All 836 diagnoses are Ortho 1 case-mix, and that’s confirmed in the Grouper...
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Look beyond payment with M1016 and ROC
I wanted to clarify the use of M1016 when you’re changing diagnosis codes at a resumption of care. In this circumstance, would you change the codes in M1016 at recertification or just keep an eye on...
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V53.99 is not a wound VAC code
A treat today … no tricks. Another clarification on wound VAC coding … I’ve posted several pressure ulcer/wound VAC answers lately (look in the archives of this blog, or click on the keywords at the...
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Separate clinicians can do SOC OASIS and ‘first visit’
It seems that many agencies believe that the SOC OASIS needs to be done by the same clinician who did the first visit, but that’s not true. The initial assessment does not have to done by the same...
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An example of clinicians doing the skilled visit and comprehensive assessment
I posted late Tuesday on clinicians doing a skilled visit and the comprehensive assessment. I’ve received several requests for an example, so here you go! A referral on a patient requires a visit at...
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Don’t code yourself for Thanksgiving!
Watch yourself this Thanksgiving, or you might become the subject of an E code: E015.1: Injury due to activities: grilling and smoking food OR MAYBE E015.2: Injury due to activities: cooking and baking...
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