Ensuring accurate diagnosis coding is paramount for home health agencies, especially with the Patient Driven Groupings Model (PDGM) and the critical role of the Face-to-Face encounter. Medical reviews and initiatives like the Review Choice Demonstration (RCD) have amplified the need for precise coding practices. Furthermore, the primary diagnosis significantly influences reimbursement calculations under PDGM, as it dictates the Clinical Grouping component of the case-mix. Incorrect coding translates directly to incorrect payments, impacting your agency’s financial health.
Therefore, aligning the principal or primary diagnosis on the home care plan with the documented Face-to-Face encounter is not just best practice—it’s essential for compliant documentation and a healthy bottom line. The primary diagnosis must represent a condition actively addressed and treated during the Face-to-Face encounter, with this treatment clearly documented in the encounter note.
Building on previous discussions about Face-to-Face encounters, this article addresses a fundamental question home health agencies frequently ask: What truly determines the primary diagnosis in home care?
The Face-to-Face Encounter: Foundation for Primary Diagnosis
A common point of confusion arises when clinicians identify conditions, such as wounds, that were not explicitly mentioned in the initial Face-to-Face encounter documentation. So, what happens when a new issue emerges as the primary reason for home health services?
Scenario: Discovering an Unmentioned Wound
Question: If a clinician discovers a wound during the initial home visit that wasn’t documented in the existing Face-to-Face encounter, can this wound become the primary diagnosis?
Answer: Yes, but with a crucial condition. If this newly discovered wound is determined to be the primary reason for requiring home health services, and it will be listed as the principal or primary diagnosis on the care plan, then the physician must address and treat this wound during a Face-to-Face encounter. Furthermore, this treatment must be explicitly documented within the encounter note.
Image alt text: A home health nurse carefully assesses and documents a patient’s wound during a home visit, emphasizing the importance of accurate wound evaluation for effective care planning and diagnosis coding.
Failing to ensure the Face-to-Face encounter reflects the primary diagnosis can lead to a common denial reason during audits: “The required face-to-face encounter is not related to the primary reason for home health services.” This highlights the critical link between the encounter and the coded diagnosis.
Addendums and Diagnosis Queries: Not a Solution for Untreated Conditions
Question: Can an addendum to the Face-to-Face encounter or a diagnosis query and confirmation retroactively address a condition that was not initially treated during the encounter?
Answer: No, neither addendums nor diagnosis queries are sufficient when the condition in question is the primary reason for home health services and is intended to be coded as the principal diagnosis. The core requirement is that the condition must have been actively addressed and treated during the Face-to-Face encounter itself.
An addendum cannot legitimately document treatment for a wound, or any condition, that was not actually assessed and managed during the original encounter. Similarly, a diagnosis query can confirm the presence of a condition, but it does not retroactively fulfill the Face-to-Face requirement of active treatment during the encounter for a condition that was not addressed at that time.
Defining “Active Treatment” in the Face-to-Face Context
The term “active treatment” is central to this discussion, yet its definition in the context of Face-to-Face encounters can be unclear. Auditors specifically look for diagnoses that were actively treated during the encounter.
Understanding Active Treatment:
While a definitive regulatory definition of “active treatment” is lacking, we can understand its practical implications in home health coding. Simply listing a diagnosis on the treatment plan with instructions like “continue medications,” “stable condition,” or “continue to monitor” generally does not constitute active treatment for the purposes of the Face-to-Face encounter and can raise red flags during audits.
Physician Addendums: Correcting Omissions, Not Adding New Treatment
There is a scenario where an addendum can be useful. If active treatment did occur during the Face-to-Face encounter, but the physician inadvertently omitted clear documentation of this treatment in the original encounter note, a physician addendum to the original Face-to-Face encounter note is permissible. Crucially, this addendum must document treatment that actually took place on the date of the encounter.
It’s important to note that addendums created by the home health agency and merely signed by the physician are not acceptable. The addendum must originate from the physician and reflect their actions during the encounter.
In situations where no active treatment was provided for the condition that becomes the primary diagnosis, a new Face-to-Face encounter is unequivocally required.
Instances Requiring a New Face-to-Face Encounter
Beyond the scenario of discovering a new primary diagnosis, several other situations necessitate obtaining a new Face-to-Face encounter to ensure accurate primary diagnosis coding and compliance:
- Condition Resolution: When the allowed practitioner documents that the actively treated condition is resolved during the Face-to-Face encounter, and a different condition emerges as the primary need for home health.
- Non-PDGM Acceptable Primary Diagnosis: If the actively treated condition documented in the Face-to-Face encounter is not a diagnosis recognized as an acceptable primary diagnosis under PDGM guidelines.
- Pre-operative Notes: When the Face-to-Face encounter note is solely a pre-operative assessment, and home health services will focus on skilled post-operative care for a different condition.
- Inpatient Stay Documentation (Without Direct Admit): If the Face-to-Face encounter note originates from an inpatient hospital stay, and the patient was not directly admitted to home health services immediately following that stay.
- Community Physician Encounters (Wrong Provider Type): When the Face-to-Face encounter is documented by a community physician (e.g., urgent care, specialist) who will not be the certifying physician for home health, or a non-physician practitioner not working under the direction of the certifying physician. It’s essential to remember that if a non-physician practitioner is the certifying allowed practitioner, the community Face-to-Face encounter must also be performed by the same non-physician practitioner type.
Given these numerous potential pitfalls, it’s understandable why many Face-to-Face encounters initially received by home health agencies may not fully meet the necessary criteria for compliant primary diagnosis coding.
Image alt text: A close-up view of a medical professional reviewing a patient’s chart, highlighting the detailed attention required for accurate diagnosis coding and Face-to-Face encounter compliance in home health.
The Risk of Premature Coding
Question: Since the Face-to-Face encounter can occur within thirty days prior to the start of care, is it acceptable to code the chart and finalize the plan of care before obtaining a valid Face-to-Face encounter note?
Answer: Absolutely not. Coding a home health chart prior to securing an adequate Face-to-Face encounter note is a risky practice that almost inevitably leads to auditing issues and increased administrative workload. Recoding charts to correct initial errors is inefficient and resource-intensive.
Some agencies mistakenly finalize the plan of care and send it to the certifying allowed practitioner for signature before the Face-to-Face encounter is even completed. This practice is fundamentally flawed because the certification must include the date of the Face-to-Face Encounter, which cannot be certified until the encounter has actually taken place.
Best Practice: Face-to-Face First, Coding Second
It is strongly recommended that home health agencies never code a new Start of Care Plan of Care without first possessing a Face-to-Face encounter note that clearly supports the primary diagnosis and demonstrates active treatment of that condition during the encounter. Prioritizing the Face-to-Face encounter ensures accurate primary diagnosis coding from the outset, leading to smoother claims processing, reduced audit risk, and appropriate reimbursement for the valuable services your agency provides.
