Widespread Probe Results and Review Notification – IA - RHHI Home Health PPS Claims with a Primary Diagnosis of 344.61—Cauda Equina Syndrome with Neurogenic Bladder
As a result of the analysis of errors related to the widespread probe review for topic 5THCZ for claims reviewed between June 30 2006, through January 2, 2007, Cahaba will be initiating a continuing widespread review for home health PPS providers. The topic code for this review will be 5THDT, and will select home health PPS claims with a primary diagnosis of 344.61. Claims will be selected across the provider community billing these services that meet the parameters of the edit. Once selected, the claims will be reviewed for medical necessity (e.g. compliance with CMS’ guidelines, contractor Local Coverage Determinations (LCDs), correct billing and coding). Results of the widespread probe review are summarized below.
Error rate: 41.14%
Number of providers reviewed: 54
Fifty percent of the denials received by providers were related to the primary diagnosis being downcoded, or denial reason code 5HRHD—HIPPS reduced—incorrect diagnosis. Often, the home health care agency bills a primary diagnosis of 344.61—cauda equina syndrome with neurogenic bladder, rather than the more appropriate primary diagnosis code of 596.54—neurogenic bladder, NOS—loss of bladder control most often due to spinal nerve damage from injury or neurological disease. According to Ingenix’s “Coder’s Desk Reference for Diagnoses,” “Neurogenic bladder is the result of many conditions, including cauda equina syndrome, injury to the spine and spinal cord, spondylitis, neoplasms, fractures, and congenital defects. When the neurogenic bladder is not due to a spinal condition, it is classified to one of the bladder dysfunction categories.” Simply, a primary diagnosis or 596.54—neurogenic bladder, NOS, is generally used in patients with a neurogenic bladder cased by any other disease process/injury than cauda equina syndrome.
Ingenix’s “Coder’s Desk Reference for Diagnoses” also further clarifies the cauda equina syndrome diagnosis code, “The ICD-9-CM code of 344.61—indicates a condition due to a compression of the lumbosacral nerve roots, including symptoms of a dull aching pain in the sacral region and/or pain in the legs. There is weakness or paralysis of the muscles. These symptoms slowly progress and a loss of bladder control may eventually occur. When a neurogenic bladder is caused by cauda equine syndrome, code 344.61 is assigned.”
Refer to the ICD-9-CM alphabetic index when selecting a code, and verify that the code is correct by checking it in the tabular listing. The diagnosis of cauda equina syndrome must be well documented and clearly evident in the medical history in order to support this diagnosis. Proper documentation of this case-mix diagnosis is essential in supporting the billed HIPPS code and preventing a possible downcoding denial.
Another 20% of claims were denied as not medically necessary, or denial reason code 5HMED—medical necessity not supported in the record. Medicare pays for services that are medically necessary for the patient’s condition when they qualify for home health. For nursing or therapy, it must be documented not only that the services did require the skills of that professional, but also that the patient’s condition warranted the services. Nursing visits may be appropriate for observation and assessment when the documentation shows the likelihood of change in a patient’s condition and requires a skilled nurse to identify and evaluate the patient's need for possible modifications of treatment or initiation of additional medical procedures. For therapy, it is important to document specific treatment delivered each visit, along with objective measurements of progress. Subjective statements such as "walking further" or "progressing well" do not alone support the coverage of further therapy visits. See the CMS IOM, Pub.100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2, 40.1.2.1 and 40.2 for more information.
Page last updated: April 26, 2007
