What to Do When Faced with a Questionable Encounter

As the first month of PDGM wraps up, it is important to remember that detailed clinical documentation is essential from any provider. Lack of specificity in documentation can lead to the submission of claims that contain a primary diagnosis that does not fall into one of the 12 clinical grouping categories. These “Questionable Encounters” are primary diagnosis codes that are not specific enough to support the need for home health services that result in a return to provider (RTP) and ultimately delays in payment.

Recently, questions have been raised if questionable encounters have an impact on the timely initiation of care. CMS released their quarterly Q&A on January 21, 2020 which provided guidance for M0104 Date of Referral if the diagnosis does not fall into a PDGM clinical grouping.   When a valid referral is received by an agency even if the physician’s primary reason for home health will be a non PDGM Clinical Grouping diagnosis, the patient should be assessed and admitted to service if the Medicare Home Health eligibility requirements are met.  The assessing clinician should communicate and collaborate with the physician as additional diagnosis or more specific diagnosis may be identified.

January 2020 CMS Quarterly OASIS Q&A on M0104

QUESTION 3: A complete referral is received from a physician at an inpatient facility on 01/01/2020 and has a diagnosis that does not fall into a PDGM clinical grouping; patient is discharged to home health on 01/01/2020. Intake staff calls physician requesting a more specific diagnosis. The more specific diagnosis is received on 01/04/2019 and care is started on 01/05/2020. Will M0104 be changed to 01/04/2020 based on the update to the specificity of the diagnosis?

ANSWER 3: M0104 specifies the referral date, which is the most recent date that verbal, written, or electronic authorization to begin or resume home care was received by the home health agency.  A valid referral is considered to have been received when the agency has received adequate information about a patient (name, address/contact info, and diagnosis and/or general home care needs) and the agency has ensured that the referring physician, or another physician, will provide the plan of care and ongoing orders.

In the scenario described, if your agency received adequate information as outlined above (including a relevant diagnosis) a valid referral is present on 1/1/2020 to allow the home health admission to be initiated and the M0104 date would be based on the date the referral was received. The assessment process, along with collaboration with the physician, may lead to identification of additional diagnoses for care planning and/or reimbursement purposes.

Read the full January 2020 CMS Quarterly OASIS Q&As here.

Here are a few additional best practice strategies in approaching questionable encounters:

Code to the highest specificity. For example, if you receive face to face (F2F) encounters documenting muscle weakness (generalized) M62.81 as the primary diagnosis, the physician must be queried to determine if the patient has had an exacerbation of another disease/illness such as congestive heart failure, COPD, etc. Avoid symptom codes and code the condition. Remember, that face to face encounter documentation must also support the primary diagnosis and will need to be updated to reflect the more specific information.

Educate. It is critical to provide continuous education to departments within your agency as well as referral sources. Ensure that your referral and intake team can recognize questionable encounter codes. Flagging this issue early in the intake process can help to mitigate a return to provider (RTP) claim and delays in payment. In addition, provide clarification to referral sources on the need for more specific diagnosis codes and detailed documentation.

Develop a query process. To ensure sound and effective communication, it is important to develop a formal query process in your agency. A query is a communication tool or process to clarify documentation in the health record for documentation integrity and accurate coding assessment. Queries are a valuable tool for home health agencies seeking a more specific diagnosis to support the need for skilled services. A query process protects the agency from billing errors and a misrepresentation of a patient’s health history. A compliant query includes open-ended or multiple-choice formats that do not lead the provider to a specific response and are specific to the patient and episode of care. Queries should not encourage the provider to a specific diagnosis or indicate the impact on reimbursement.