Home Health & Hospice Week

Give yourself a manifestation coding refresher to avoid cash flow problems in the new year.

Do you know how to sequence codes when the focus of your patient’s care is a manifestation? Make sure you have the guidelines down pat or you could risk being caught up in new edits.

Why? On Jan. 1, the Centers for Medicare & Medicaid Services will implement edits that will return home health agency claims that contain a manifestation code as primary (see Eli’s HCW, Vol. XXIII, No. 29). Under ICD-9 coding conventions, a manifestation code may be listed only after the code for its underlying condition.

"The principal diagnosis reported on the home health claim shall be the ICD-9-CM code that is most related to the current home health plan of care," CMS instructs. "HHAs shall not submit manifestation codes as the primary diagnosis."

Remember, "the patient’s primary diagnosis is defined as the diagnosis most related to the current home health plan of care," CMS says in a MLN Matters article regarding the edits. "The principal diagnosis reported on the home health claim should be the ICD-9-CM code that is most related to the current home health plan of care. HHAs should not submit manifestation codes as the primary diagnosis."

Know These Manifestation Coding Basics

The coding guidelines for manifestations are clear — sequence the underlying condition first, followed by the manifestation. If you follow this rule, you’ll keep your claims in the clear.

Details: The ICD-9-CM Official Guidelines for Coding & Reporting advises, "Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a ‘use additional code’ note at the etiology code, and a ‘code first’ note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation."

You’ll find the same guidelines for reporting etiology/manifestation pairs, also referred to as "mandatory multiple coding" in your ICD-10 coding manual as well.

Why? When your patient is receiving care directed at a manifestation, to fully describe his condition, you must include a code for the etiology (or the cause) of the manifestation as well as a code for the manifestation (or the effect).

In addition to "use additional code" and "code first" notes in the tabular list of your coding manual, you’ll see a specific structure in the alphabetic index for etiology/manifestation pairs. Here, both conditions are listed together with the etiology code first, followed by the manifestation codes in brackets. "The code in brackets is always to be sequenced second," the guidelines state.

Hint: When verifying codes in the tabular listing if you see code titles with "in disease classified elsewhere," this is a signal that you shouldn’t list the diagnosis as primary, says coding expert Joan Usher with JLU Health Record Systems in Pembroke, Mass. Codes with this designation fall under the etiology/manifestation convention and are never permitted to be used as first listed diagnosis codes, she says. "But remember, not all manifestations have this designation," she adds.

Consider this coding example when you ramp up for the new edits that will reject claims with manifestation codes as primary.

Your new patient was referred to your agency by her primary physician for assistance with medication adjustment for behavioral issues due to dementia related to her Alzheimer’s diagnosis. Her behavior has escalated with aggressiveness.

The focus of your care is the patient’s dementia-related behavioral issues, but when you look up 294.11 (Dementia in conditions classified elsewhere with behavioral disturbance) in the tabular list of your coding manual, you’ll notice a note at 294.1 (Dementia in conditions classified elsewhere) that reminds you to code first an underlying physical condition, Usher points out. In this case, you’ll report 331.0 (Alzheimer’s disease) as primary in M1020a, followed by 294.11 in M1022b. v

Note: The CR is online at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1405OTN.pdf. The MLN Matters article is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8813.pdf. Find the Category 4b — OASIS Data Items under OASIS Questions & Answers here: www.oasisanswers.com/aboutoas_links.htm.