Home Health Plan of Care: Primary Diagnosis

Question: What happens when we have a combination diagnosis code listed on our plan of care for the first code diagnosis? What if we are only providing home health for one of those conditions? Coding conventions guide us on what to list as the primary diagnosis.

Answer: The face-to-face clinical encounter must be related to the primary reason for home health services. These conditions must be addressed within the encounter or be evident in documentation that has been authenticated by the allowed provider performing the face-to-face. Examples CAN include but are not limited to, medications for the condition, laboratory tests related to the diagnosis and past medical history conditions listed. Medical Review nurses utilize clinical judgement for the synthesis of the clinical documentation. Etiology and causative conditions are taken into consideration when the face-to-face documentation is sufficient to demonstrate the condition. The plan of care and interventions should address the etiology (first diagnosis code) as well as any other pertinent diagnoses.

Additional Resources

• Home Health Face-to-Face Encounter
• Medicare Benefit Policy Manual Chapter 7 — Home Health Services (PDF)