How to Prevent Common Errors in Home Health and Hospice Coding

Coding errors in home health and hospice can lead to significant consequences, including audits, reimbursement delays, and financial penalties. As the Centers for Medicare & Medicaid Services (CMS) intensify their regulatory oversight, home health and hospice agencies are under increasing pressure to ensure that every diagnosis code is not only accurate but fully supported by documentation and compliant with current regulations.

In this blog, we’ll explore the most common coding errors in home health and hospice and how to prevent them.

Common Errors in Home Health Coding

Under the Patient-Driven Groupings Model (PDGM), accurate coding is crucial for proper reimbursement. Errors in ICD-10-CM coding can cause claims denials, revenue loss, audits, and payment takebacks.

• Incorrect Primary Diagnosis Codes – Using vague, symptom-based, or non-groupable codes as the primary diagnosis can lead to claim rejections and lowered reimbursement.

• Using Outdated Codes – Outdated or incorrect ICD-10-CM codes that don't reflect the patient's condition can lead to claim rejections.

• Missing or Inaccurate Comorbidity Adjustments – Overlooking comorbid conditions can lead to lower case mix scores, reduced reimbursement, and potential compliance risks.

• Overuse of Unspecified Codes – Using unspecified diagnosis codes too frequently, even when more specific options are available, can lead to inaccurate data and claim denials.

• Incomplete Clinical Documentation – Accurate coding depends heavily on clear, specific, and comprehensive clinical notes. If the documentation does not provide enough detail to assign the correct ICD-10-CM code, coders should query the provider for clarification.

• Failure to Indicate Laterality – Some ICD-10-CM codes require specifying laterality (left, right, or bilateral). Coders should carefully review the documentation to ensure the correct laterality is selected.

• Improper Code Sequencing – Incorrect sequencing of diagnosis codes can lead to denials and misrepresentation of the primary diagnosis.

• Inconsistent Diagnosis Coding – When diagnosis codes are not aligned with the patient's clinical documentation or plan of care, it can lead to discrepancies that may affect reimbursement and compliance.

Common Errors in Hospice Coding

Payers closely scrutinize hospice eligibility and length of stay, making accurate documentation and coding essential. Errors in ICD-10-CM coding, HIS/HOPE reporting, or physician narratives can lead to audits and denied claims.

• Incorrect Terminal Diagnosis Coding – Using inaccurate diagnoses or omitting key comorbidities may result in claim rejections and audits.

• LCD (Local Coverage Determination) Non-Compliance – Not aligning documentation and coding with applicable LCD guidelines can lead to claim denials, repayment demands, compliance issues, and inaccurate patient eligibility assessments.

• Improper Sequencing of Codes – Incorrect code sequencing on hospice claims can cause denials and misrepresent the primary diagnosis.

• Inconsistent Diagnosis Coding Across Documentation – Variations in diagnosis coding across hospice records can lead to compliance issues and misrepresentation of the patient’s condition, potentially affecting claim approval and care accuracy.

• Misclassification of Related and Unrelated Diagnoses – Incorrectly identifying related and unrelated diagnoses can impact hospice eligibility, lead to claim denials, and result in compliance issues.

• Incomplete Clinical Documentation – Inaccurate or vague documentation in hospice can lead to coding errors, resulting in denied claims or non-compliance.

How to Prevent Common Home Health and Hospice Coding Errors?

Preventing common home health and hospice coding errors involves ensuring accuracy in documentation, proper understanding of coding guidelines, and ongoing education for coding professionals. Here are some key strategies to reduce coding errors in both home health and hospice:

• Stay Updated on ICD-10-CM Codes – Regularly review and update ICD-10-CM codes to ensure the most current and appropriate codes are used, as these are updated annually.

• Use PDGM-Compliant Primary Diagnosis – Avoid non-groupable or symptom-based primary codes that delay or deny payment. Ensure the primary diagnosis reflects the condition most impacting skilled services.

• Capture All Relevant Comorbidities – Comorbid conditions can increase the case-mix weight under PDGM. Review patient history and medication lists to identify all clinically relevant diagnoses.

• Prevent Incorrect Terminal Diagnosis Coding – Coders should thoroughly review documentation to accurately identify the primary terminal condition and include all relevant comorbidities.

• Eliminate Overuse of Unspecified Codes – Avoid the overuse of unspecified codes. Always choose the most specific code that reflects the patient’s condition.

• Ensure Accurate and Complete Documentation – Ensure that clinical documentation is thorough, specific, and clear. The provider should document all diagnoses, symptoms, and comorbidities to support the codes assigned.

• Be Mindful of Laterality – When applicable, confirm that laterality (left, right, bilateral) is specified in the codes to reflect the correct diagnosis.

• Properly Sequence Diagnosis Codes – Ensure that the primary diagnosis is listed first and accurately reflects the primary reason for care, while secondary diagnoses follow in appropriate order.

• Ensure Consistency in Diagnosis Coding – Verify that the diagnosis codes used in the clinical documentation, care plans, and claims submissions are consistent and aligned.

• Avoid LCD Non-Compliance – To prevent LCD-related errors in hospice coding, documentation must align with the specific clinical criteria, such as evidence of functional decline or disease progression.

• Train and Educate Coding Staff – Provide continuous training and education to coding staff about updates in ICD-10-CM codes, medicare policies, and specific home health and hospice coding guidelines.

• Implement Regular Audits and Reviews – Conduct regular internal audits to identify any recurring errors or areas of improvement in coding practices.

Partnering with Cliniqon

Cliniqon is the ideal partner for home health and hospice agencies looking to strengthen coding accuracy, compliance, and reimbursement outcomes. Our coders are registered nurses and hold several certifications, including CPC, BCHH-C, and HCS-D, demonstrating their expertise and commitment to accuracy and compliance in medical coding. Additionally, we have MDs on board for extensive clinical records reviews and complicated chart analysis. When you choose Cliniqon, you're gaining more than just a coding service—you’re partnering with a team dedicated to enhancing your agency’s clinical performance and financial success.