What are questionable encounters under PDGM?

by Keith Grunig

Stressed at work home health nurse


What are questionable encounters under PDGM?

We're nearly 4 years into PDGM.  We've learned a lot.  But sometimes old habits die hard.  For years and years, Home Health Agencies could minimize the importance of OASIS and diagnosis coding because they knew that they could impact reimbursement through therapy and utilization visits.  Because of that, agencies got into the habit of putting codes that may have described the symptom of what was happening with a patient like Muscle weakness (generalized) (M62.81).  

CMS never really liked those codes to begin with.  CMS always wanted the underlying cause of a symptom like Muscle weakness- why is the patient weak?  Is it because of a stroke?  Infection?  Dimentia?  Surgery?  There are a lot of reasons why a patient can experience weakness.  CMS wants to know the reasons.  

What is a questionable encounter in home health?

Simply put, a questionable encounter is a primary diagnosis code that is not PDGM compliant.  There are a lot of ICD-10 Codes.  Did you know there are over 29,000 ICD 10 codes that are questionable encounters- meaning a primary diagnosis code that is not acceptable under PDGM rules.  There are various reasons for why they aren't acceptable.  Some are symptom codes, others not specific enough, some not appropriate in a home health setting.  For some light reading on a comprehensive list of questionable encounter codes courtesy of National Association of Home Care and Hospice, you can find them here.  

Decision Health published the Top 10 Questionable Encounters in an article from Home Health Line.  

ICD code Description Periods count
M62.81 Muscle weakness (generalized) 43
R53.1 Weakness 28
R26.9 Unspecified abnormalities of gait and mobility 20
R26.89 Other abnormalities of gait or mobility 19
R29.6 Repeated falls 17
R55. Syncope and collapse 14
N18.6 End stage renal disease 13
M19.90 Unspecified osteoarthritis, unspecified site 13
M54.50 Low back pain, unspecified 12
C34.90 Malignant neoplasm of unsp part of unsp bronchus or lungs 12

What happens if you submit a Questionable Encounter?

That's an easy one.  You don't get paid.  CMS may deny the claim or could do a Return to Provider (RTP).  Either way, the agency can provide care for the patient, but it won't receive any reimbursement from CMS. 

What are PDGM codes?  

Well, the answer is: NOT the list above.  There are equally as many acceptable PDGM compliant codes as Questionable Encounters (QE). Prior to PDGM, many agencies could get by by throwing codes on the OASIS as M1021 and there were 5 additional codes.  The top 6 codes were payer codes and the rest didn't really matter.  Any agency could come up with 6 codes.  PDGM changed and now gives the primary diangosis in M1021, and then 24 slots to code  (the top 6 codes matter for risk adjustment purposes).  The first code, M1021, "the face-to-face encounter must be related to the primary reason for home health services."  There is no exception to this.  Face to Face is the most common reason for denials in home health.  Because PDGM is home health specific, many physicians or qualified providers haven't really received a lot of education about PDGM.  So, many face to face (F2F) have a referral for a vague reason like "muscle weakness."  Pre-PDGM, that would work.  Post PDGM, if agencies want to get paid, that doesn't cut it.  You can find the Face to Face Requirments in the Medicare Benefit Policy Manual Chapter 7.  Section 30.5.1 you can find the link here.  

Many agencies don't have the expertise to code appropriately any more.  PDGM requires coding be done to the highest specificity.  That takes years and years of practice, a lot of resources, and specializing in coding for home health.  CMS changed the game with PDGM.  Agencies probably aren't equiped to be able to code the way that CMS requires it.  We have several articles about PDGM.  You can find them How is PDGM CalculatedPDGM for DummiesWhat is PDGM in Home Health?  

To avoid questionable encounters, agencies would do well to partner with Home Care Answers which don't let Questionable Encounters get past go.  It won't be coded by our team and we'll request information to get the best documentation to support our coding recomendations.  

With OASIS and Coding being the only way that agencies are paid, Home Care Answers provides the most informed, accurate, timely, and collaborative OASIS and coding review services.  Agencies' viability rests on it.  This is not somewhere to wing it, to scimp on it, or to ship it to offshore companies to save a few bucks.  We provide a free trial and recap so that you can see where your agency stands.  

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