Responses for 11/17; New scenarios for 12/1

Good Monday morning,

I hope everyone enjoyed the Thanksgiving holidays last week!  Here are the responses from 11/17 questions and scenarios.


What does the home health resource group, or HHRG, measure?

The Medicare Home Health PPS recognizes that different patients use different amounts of resources. The system attempts to predict patient resource use and reimbursement based on a case-mix adjustment model and three distinct dimensions or domains:  CLINICAL status (severity), FUNCTIONAL status (severity), SERVICE (therapy) utilization.

The HHRG measure is unique to Medicare home health. It is based on responses to OASIS M-items that contribute points from each of the above domains to a case-mix score. The case-mix score is then expressed as a Home Health Resource Group, or HHRG.

The HHRG measures the severity of the patient’s condition and probable need for home health resources. Theoretically, the sicker the patient is the more complex his or her condition, the higher the Medicare reimbursement will be.


Patient is admitted to home health for aftercare of a CABG after an MI six weeks ago. Patient has diagnoses of CAD, hypertension and CHF. He smoked cigarettes for 20 years but quit five years ago. Patient has been started on Coumadin and PT/INRs will be performed by nurse.

Z48.812, Encounter for surgical aftercare following surgery on the circulatory system

I25.10, Atherosclerotic heart disease of native coronary artery without angina pectoris

I10, Essential hypertension

I50.9,  CHF

I25.2, Old myocardial infarction (healed) – The MI is only acute if it occurred within the last four weeks, therefore the code for Old MI is correct in this example.

Z51.81, Encounter for therapeutic drug level monitoring

Z79.01, Long-term (current) use of anticoagulant

Z48.01, Encounter for surgical wound dressing – This is an optional code.

Z87.891, Personal history of nicotine dependence = History of tobacco use is REQUIRED coding for the category I25, if applicable.


My patient’s surgical wound appears to be infected. There is purulence and slough at the incision site that has dehisced. The patient is receiving IV antibiotics. M1342 (status of surgical wound) is response 3 (Non-healing). We will be providing wound care. How should I code this case?

Postoperative infection (998.59) and postoperative dehiscense (998.3x) are both complication and should be confirmed by the physician. Response 3 (not healing) on M1342 (Status of surgical wound) can provide a clue that the patient has a complication, but you are not allowed to assign a complication as a diagnosis without physician agreement. If physician agrees, ALWAYS sequence Dehiscence before postoperative infection. Don’t forget that since this is a complicated wound, a V-code for surgical dressing change may NOT be used.

New Scenarios for 12/1:


Could you explain how to use V54.81 and V54.82 when coding patients who have had a joint replacement?


This elderly woman was being treated for her right eye age-related cortical cataract at this day-surgery center. After the procedure was complete, the patient suffered a postoperative hemorrhage of the eye. This was addressed by the surgeon. What is the correct code(s)?


M1016 diagnoses are limited to diagnoses that have undergone medication changes within the last 14 days.  True or False?

I look forward to hearing from you,


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