Perplexing question- Diagnosis Order HELP PLEASE

nancynurz · Sep 16, 2004

If nursing is a skill, the nurse has to "complete" the OASIS and the primary diagnosis is the one driving nursing service. Order for skilled services by priority are: SN, PT, OT, then ST. PT can recert and be a primary skill. OT can be primary after SN &/or PT discharge.

Monica RN,BSN · Sep 16, 2004

Thanks....

I am being told that a PT diagnosis is ALWAYS primary... True or false?

I do the OASIS for alot of the admits.... So am I correct if I say the nurse diagnosis SUPERCEEDS a PT diagnosis? or not....

nancynurz · Sep 16, 2004

http://www.cms.hhs.gov/oasis/usermanu.asp

This is where I get my information. It states in the manual that nursing takes precedence over PT, you can show it in black and white. There is also a list of State contacts for OASIS questions. Most states offer OASIS 101 training; very helpful to be trained by the same people who audit you submission errors :)

Home Health Columnist / Guide · Sep 16, 2004

the service that will be providing the most care to the patient should be listed as primary.

from 3m oasis integrity project: http://www.nahc.org/nahc/legreg/3mnoip.pdf

recommendations from expert design forum

optimal question: primary diagnosis: what diagnosis is driving the home health plan of care?

secondary diagnoses: what diagnoses are addressed by the home health plan of care or have the potential to affect the plan of care, affect progress and rehabilitationpotential or justify all services provided?

optimal technique: determine diagnostic statements after completion of assessment, determining patient's needs and formulation of home health plan of care.

tips:

follow icd coding guidelines ([color=#3365ff]www.cdc.gov/nchs/data/icd9/icdguide.pdf) and use current coding books.

follow directions in home health agency manual #11 (sec. 234.7 (11-13).

refer to cms guidance document, "diagnosis coding for medicare home health under pps", ([color=#3365ff]cms.hhs.gov/providers/hhapps/hhdiag.pdf) for examples.

refer to cms oasis implementation manual, chapter 8, attachment d for the use of v-codes.

primary diagnosis:

* diagnosis most related to the current plan of care developed by the agency.

* represents the most acute condition and most intensive services.

* may not be related to the reason for hospitalization.

* may be best described by a v-code.

secondary diagnoses:

* conditions addressed by the plan of care.

* conditions that coexist and have the potential to affect the plan of care.

* justify disciplines and services rendered.

* may be described as a v- or e-code.

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two examples:

mr smith has dx of chf which resulted in 2 hospitalizations in the past month, djd, unsteady gait discharged with new cane. services requested rn and pt

rn eval reveals 10 medications, four new, multiple old meds from three years ago in the home. pt was able to walk upstairs easily with cane to show rn bathroom for safety eval.

rn expects nursing to be in longer than pt so chf is listed as primary diagnosis.

miss eisenhower has dx of chf, treated with one dose iv lasix, djd and is status post knee replacement. orders for rn to remove staples in five days, pt for home exercise program

rn eval reveals pt on 4 meds; knowledgable about purpose, schedule and side effects. current rx recently refilled in the home. pt able to describe nas diet + meal plan. follows writtenmed schedule posted on refrigerator. pt states told she went into mild chf due amount of fluids used in operation. ambulatory with new walker, only 20 feet in home and has first floor powder room.

rn expects nursing in only for 2-3 further visits but needs extensive pt.

pt aftercare of surgery, djd then chf listed.

if its a tossup, then list sn as primary.

Home Health Columnist / Guide · Sep 16, 2004

order for skilled services by priority are: sn, pt, ot, then st. pt can recert and be a primary skill. ot can be primary after sn &/or pt discharge.

st can be an admitting stand alone service under medicare.

if it is managed care company (not medicare or medicaid hmo ) requesting ot only, ot can be an admitting service if your agency has therapist who are willing.

nancynurz · Sep 16, 2004

Hooboy! I have no idea where I got SN is primary from :imbar I've had it placed in my brain and gold-plated, so now I've gotta train myself back out of it! Even the Palmetto GBA manual CLEARLY states:

"The HHA enters the ICD-9-CM code for the principal diagnosis. This code must be the full ICD-9-CM diagnosis code, including all five digits where applicable. When the proper code has fewer than five digits, it is not zero filled. It may or may not relate to the patient's most recent hospital stay, but it must relate to the services the agency is rendering. If more than one diagnosis is treated concurrently, enter the diagnosis that represents the most acute condition and requires the most intensive services."

Sorry Monica-- I've seen that passage tons of times, yet that mental block is still there. It took a year before I remembered to use N/A for the therapy MO item on my Medicaid patients and a good two years for the skin lesions.

CHANTELRN28 · Sep 17, 2004

I THINK IT HAS TO DO WITH WHO WILL BE IN THE HOME THE LONGEST AND ALSO WHO WILL GAIN YOUR AGENCY THE MOST MONEY! :nurse:

I have a question regarding those who recieve physical therapy.
I was instructed that if physical therapy is ordered, then the primary diagnosis has to be something ortho related, or has to be weakness, or unsteady gait, etc.
My thought is for example, if the patient was admitted for, let's say wound care, but needs therapy.... I would think the primary would be why the nurse needs to be there rather than why the therapist needs to be there....
someone please help me out on this one.....
Thanks!!

Monica RN,BSN · Sep 18, 2004

Thanks for your help.......

renerian, BSN, RN · Sep 27, 2004

The most money!! LOL feels like that is a mesage sometimes doesn't it?

renerian