O-11-609 Primary Focus of Care/Diagnosis Code Review

🎯 PURPOSE

To provide guidance on how to review for applicable primary focus of care/diagnosis codes related to the home health episode.

IMPORTANT TO NOTE:  The reviewer is responsible for ensuring that the Primary Focus of Care is supported by clinical documentation. The patient’s primary diagnosis is defined as the diagnosis most related to the current home health plan of care. The primary diagnosis may or may not relate to the client’s most recent hospital stay; however, it must be directly related to the services being provided by the home health agency. When more than one diagnosis is being treated concurrently, the diagnosis that represents the most acute condition and requires the most intensive services should be identified as the primary diagnosis.

🔄 PROCESS

When reviewing a Start of Care (SOC), Recertification, Follow-Up/Change in Condition, or Resumption of Care (ROC), the reviewer should evaluate the primary focus of care to ensure that:

  1. The selected primary diagnosis is supported by clinical documentation.
  2. The diagnosis is directly related to the current home health plan of care and services being provided.
  3. The clinical summary clearly supports the identified primary focus of care.
  4. When multiple diagnoses are being treated concurrently, the diagnosis representing the most acute condition and requiring the most intensive services is identified as the primary diagnosis.
  5. The applicable primary diagnosis code is listed as Diagnosis #1 in the medical record.

The reviewer should ensure that the primary focus of care and corresponding diagnosis code accurately reflect the condition driving the current home health episode and are consistent with the clinical documentation and services provided.

Start of Care Documentation Review

Recertification Review

Resumption of Care Review

Changes in Condition or in Focus of Care

Start of Care Documentation Review (SOC):

  1. Complete review of documentation in Task : 1- REVIEW EVALUATION DOCUMENTATION. When viewing the “Visit note” from task one the reviewer will review client’s primary diagnosis code listed in the #1 order column from the PDF note.


  1. View Coordination Notes Report to cross reference diagnosis code listed in the visit note to the Clinical Comment-Intake care coordination note entered by intake to ensure these match.

  1. Select View POC Order within Task 1 and locate the Primary Focus of Care pathway on the PDF to ensure the diagnosis code listed in narrative pathway matches what was identified from the visit note and Clinical Comment- Intake care coordination note.  

NOTE:

a)  This section should state the primary diagnosis code only. It should not include more than one diagnosis code or any other text/narrative.  If more than one diagnosis is listed, collaborate with assessing clinician and edit pathway in Task 2 of review process before approving for coding.

b) If the <<<Primary Focus of Care>>> section conflicts with the diagnosis code from the visit note or clinical comment intake note. Begin collaboration via email or phone call with assessing clinician, branch clinical compliance specialist, and clinical supervisor to determine if new F2F is required.

  1. Review reminder of narrative to ensure additional narrative is present that supports the primary focus of care and make any required changes following collaboration with assessing clinician in “Edit POC order” from Task : 2- Review/Edit/Approve 485 ORDER.

Examples of additional narrative to support the primary focus of care:

a) PFOC: CHF. Skilled nursing to see client for 1wk3 to provide education and assessment related to CHF. Education needed for weight monitoring and fluid intake restrictions.

b) PFOC: OA of multiple sites. Physical therapy to treat for chronic pain related to osteoarthritis. Client reports pain of 6/10 with activity in bilateral knees. HEP and pain management required. 

c) PFOC: DM2. Client discharged from hospital with new diagnosis of type 2 diabetes. Client has new order for insulin. Skilled nursing to provide assessment and education of administration.

Recertification Review:

  1. Begin review of documentation in Task : 1- REVIEW EVALUATION DOCUMENTATION. When viewing the “Visit note” from Task 1, review client’s primary diagnosis code listed in the #1 order column from the PDF note along with the list of client’s co-morbid diagnosis/conditions.


  1. Select View POC Order in Task 1 to review Primary Focus of Care pathway and ensure clinician has the primary focus of care listed as the diagnosis code that requires the most intensive home care services. Supporting documentation of the PFOC should be reviewed to ensure accuracy of the diagnosis code (refer to SOC Documentation Review for details and examples of supporting narrative).

Note: The primary focus of care that was applicable at time of last start of care or resumption of care may change at time of recertification. Diagnosis codes may need to be moved/adjusted if the primary focus of care has changed. (Completed in task 2)


  1. Review the list of all diagnosis codes to remove or ensure any new or applicable codes are added to the 485. Any diagnosis codes that are no longer applicable or resolved at time of recertification should be reviewed and removed in Task : 2- Review/Edit/Approve 485 ORDER from the “Edit POC order” tab.

Examples:

a)      Diagnosis codes that may resolve over time may include but are not limited to: fractures, wounds, infections, VAD maintenance, and catheter codes.

b)      New codes that may need to be added at time of recertification may include but are not limited to: new or already present wounds that were not verified at time of SOC or last ROC along with new diagnosis or client co-morbidities.

Resumption of Care Review (ROC)

  1. Prior to the review on ROC documentation it is recommended to review client attachments, orders, care coordination notes, and progress notes from the Patient Snapshot view to understand the changes that may have occurred during inpatient event and review for correct pathways, orders, and diagnosis.
  2. Review first task of ROC, Task: ROC EVALUATION DOCUMENTATION. Review “Visit Note” and “Review ROC order” following the same processes for Start of Care and Recertification. Any discrepancies with the PFOC found within the SBAR pathway should follow the collaboration process outlined in the SOC review process. Changes to ROC order will occur in step two of ROC.  

To note/differences: If client was diagnosed with a new diagnosis or inpatient event caused changes to the POC during the inpatient event the diagnosis code in the #1 spot order column may not be accurate until the ROC is coded.  

  1. Any changes or clarifications that are identified in step one of ROC review will be completed in step 2 Task: REVIEW/EDIT/APPROVE ROC ORDER prior to being sent to coding. Make changes to the Primary Focus of Care Pathway narrative under the Order Description tab.

NOTE:

a) If the inpatient event did not impact the primary focus of care, this should be clearly documented within the narrative to prevent any coding holds.

Example: <<<Primary Focus of Care>>> Type 2 diabetes (No changes to PFOC following hospitalization for UTI, diabetes diagnosis continues to require the most intensive homecare services)

b)  Any diagnosis codes that are no longer applicable or resolved at time of resumption should be reviewed and removed from POC before approving the ROC following coding.

Changes in Condition or in Focus of Care:

  1. If a client has a change in condition that requires a change in treatment or monitoring by the home health agency, the condition must be reflected in the coding sequence and in the plan of care. Wounds are a common example of a condition that could present anytime during an episode of care or may change from a secondary diagnosis to a primary diagnosis with completion of therapy during an episode.
  2. All wounds should have a corresponding diagnosis code which would require etiology clarification with the provider.
  3. Always double check new conditions, including wounds, to ensure the diagnosis code is supported in the record.
  4. If the PFOC is wound care, the diagnosis code list should be modified to reflect this.
  5. Decision Health Coding Center can be utilized as a basic coding resource: https://codingcenter.decisionhealth.com/MVC/Account/Login?ReturnUrl=%2FMVC%2FHome
  6. Questions about focus of care changes or ICD-10 coding sequencing/guidance should be directed to the clinicalsupport@adarahomehealth.com.

📅 Effective: 10/1/2026| 🛠️ Revised:  |  ✅ Approved: KD

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