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August 11, 2022
Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
US Department of Health and Human Services
Attention: CMS-1766-P
PO Box 8011
Baltimore, Maryland 21244-1850
Dear Administrator Brooks-LaSure:
On behalf of the American Health Information Management Association (AHIMA), I am responding to
the Centers for Medicare & Medicaid Services’ (CMS) proposed rule for the Calendar Year (CY) 2023
Home Health Prospective Payment System Rate (HH PPS) Update, as published in the June 23, 2022,
Federal Register (CMS-1766-P).
AHIMA is a global nonprofit association of health information (HI) professionals. AHIMA represents
professionals who work with health data for more than one billion patient visits each year. AHIMA’s
mission of empowering people to impact health drives our members and credentialed HI professionals
to ensure that health information is accurate, complete, and available to patients and providers. Our
leaders work at the intersection of healthcare, technology, and business, and are found in data integrity
and information privacy job functions worldwide.
Following are our comments and recommendations.
II. HOME HEALTH PROSPECTIVE PAYMENT SYSTEM (87FR37603)
II-B-3c(1) – Proposed Reassignment of Specific ICD-10-CM Codes Under the PDGM: Proposed Clinical
Reassignment of Certain Unspecified Diagnosis Codes (87FR37621)
AHIMA urges CMS to reconsider its proposal to reassign 159 ICD-10-CM unspecified diagnosis codes to
“no clinical group” (NA). AHIMA fully supports complete and accurate documentation and coding,
including coding to the highest specificity possible. However, there are valid circumstances when
unspecified codes can and should be used. While specific diagnosis codes should be reported when they
are supported by the available medical record documentation and clinical knowledge of the patient’s
health condition, there are instances when unspecified codes are the best choices for accurately
reflecting the healthcare encounter. As stated in the ICD-10-CM Official Guidelines for Coding and
Reporting (“official coding guidelines”), when sufficient clinical information isn’t known or available
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about a particular health condition to assign a more specific code, it is acceptable to report the
appropriate “unspecified” code. Also according to the official coding guidelines, while codes for
unspecified laterality should rarely be used, there are circumstances when these codes are appropriate,
such as when the documentation in the record is insufficient to determine the affected side and it is not
possible to obtain clarification.
The burden of obtaining the necessary information to support the reporting of more specific codes than
those on the proposed list of unspecified codes will be challenging for home health organizations. While
some home health organizations may have access to complete hospital medical records through system
integration, others without this linkage may find it difficult or impossible to obtain the information
needed to support greater coding specificity. Many home health services are provided as a “subsequent
encounter,” meaning active treatment for the initial injury has been completed, and so anatomic
specificity regarding the original injury may not be included in the home health documentation.
Requiring providers to use specific codes when the clinical information to support a more specific code
isn’t available may encourage providers to select a specific code without supporting medical record
documentation.
The proposed rule references the new Medicare Code Editor (MCE) edit for unspecified diagnosis codes
that is part of the Hospital Inpatient Prospective Payment System (IPPS). However, the codes subject to
this edit are still considered acceptable principal diagnoses under certain circumstances. If additional
information to identify laterality is unable to be obtained or there is documentation that the physician is
clinically unable to determine the laterality because of the nature of the disease/condition, then the
provider must enter that information in the claim remarks field. This information enables the Medicare
Administrative Contractor to bypass the edit and process the claim accordingly. Therefore,
reimbursement is not affected by the unspecified diagnosis code if the hospital affirms that information
to support a more specific code could not be obtained.
The diagnosis codes subject to the “unspecified code” MCE edit and the list of codes in table 1.A
associated with the HH PPS proposed rule are not consistent. A majority (114) of the 159 codes on the
home health list are not subject to the MCE edit. While the discussion in the HH PPS proposed rule
focuses on laterality, not all of the proposed codes on the list pertain to unspecified laterality. For
example, codes N70.91, Salpingitis, unspecified, and N70.92, Oophoritis, unspecified, are on the list, but
the missing specificity for these codes is acuity rather than laterality.
AHIMA agrees with CMS that all clinical conditions should be documented and coded to the highest
degree of specificity possible. However, as CMS acknowledged in its implementation of the “unspecified
code” MCE edit, it is not always possible to avoid using an unspecified code. We do not believe it is
appropriate for home health providers to be held to a higher standard for coding specificity than
inpatient hospitals, especially since the documentation to support specific codes is more likely to be
found in hospital inpatient documentation than in home health documentation.
To encourage home health providers to report specific codes and to document the clinical detail
necessary to support these codes, AHIMA recommends that CMS consider implementing an edit similar
to the MCE edit, which would promote coding specificity while still allowing the use of unspecified codes
when necessary. As CMS did with the implementation of the MCE edit, implementation of such an edit
should be delayed for a period of time to allow home health organizations time to educate providers
and coding staff. We recommend that only codes describing unspecified laterality should initially be
subject to this edit in order to allow a transition period for documentation and coding improvement
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efforts to be effective before considering expansion to additional unspecified codes. This would be
consistent with CMS’ approach for unspecified codes under the IPPS.
If AHIMA can provide any further information, or if there are any questions regarding our
recommendations, please feel free to contact Sue Bowman, senior director of coding policy and
compliance, at (312) 233-1115 or sue.bowman@ahima.org
.
Sincerely,
Wylecia Wiggs Harris, PhD, CAE
Chief Executive Officer
