Home Health & Hospice Week

Could a hospice case mix adjustment system be in your future?

Your hospice claims continue to pique the interest of the Centers for Medicare & Medicaid Services. Now’s the time to beef up the diagnosis codes you report to help keep your claims edit-proof.

Edits for hospice patients with a primary diagnosis of 331.0 (Alzheimer’s disease), 799.3 (Debility), or 496 (COPD) and a length of stay greater than 180 days continue. Plus, CMS is considering moving hospice providers to a case mix adjustment system where accurate coding is likely to play an even bigger role in how your agency is paid. Do you know how to code to ensure your reimbursement doesn’t suffer?

Why is Accurate Hospice Coding Important?

In the 2013 hospice wage index notice, CMS urged hospice providers to code thoroughly for their patients -- that means going beyond just listing the primary reason for hospice care, says Judy Adams, RN, BSN, HCS-D, HCS-O, with Adams Home Care Consulting in Chapel Hill, NC. CMS also indicated that most patients at the end of life are elderly and likely to have multiple co-morbidities, so hospice providers should code and report coexisting and additional diagnoses that are related to the primary reason for hospice in order to more fully describe the patients they are treating, Adams points out.

Plus, the official ICD-9-CM coding guidelines require coders to report additional or coexisting diagnoses that relate to the care being provided, Adams says.

As CMS considers moving to a case mix adjustment system for hospice providers, detailed coding will become even more important. "In order to account for any clinical complexities a given patient might have as a result of related co-morbidities, the co-morbidities must be included in the hospice claim," Adams says.

Pertinent: Of course, the coexisting or additional diagnoses you report must also be related to the terminal illness, Adams says. The on-line Medicare claims processing manual (Chapter 11 of Manual 100-04), the Medicare Benefit Policy Manual (100-02, Chapter 9, Section 10), and Section 418.54, Comprehensive assessment and 418.56, the Plan of Care in the hospice Conditions of Participation each describe Medicare hospice benefits as any Medicare services related to the treatment of the terminal condition for which hospice care was elected or a related condition or service, Adams points out.

Plus, hospice Local Coverage Determinations stress the need to include documentation of decline and the clinical status as a first priority, especially for non-cancer diagnoses, Adams says. "Many times the progressive changes relate to other related conditions that impact the terminal condition. The presence of many common chronic co-morbidities may impact these factors making them pertinent to the reason that hospice is appropriate for a patient," she says.

How Can You be Specific for Non-Specific Patients?

Many hospice providers have turned to 799.3 (Debility) when coding for non-specific disease hospice patients. But this code is one that has been drawing scrutiny. Alzheimer’s disease patients are also the subject of edits.

Lesson learned: Adding details to the codes you report for these patients is essential for securing reimbursement now and under the possible case mix system of the future.

Coding scenario: Mr. K. is a 90 year-old patient with moderate Alzheimer’s disease with dementia. He requires constant supervision because he wanders out of the house and becomes lost in the neighborhood even though he is developing more and more difficulty ambulating. He has increased difficulty dressing, grooming and bathing himself. He is incontinent of urine daily and has occasional fecal incontinence. His speech is limited to only one to five words a day and he has developed dysphagia. In addition to his Alzheimer’s disease with dementia, he has congestive heart failure with resultant dyspnea, orthopnea, and lack of strength.  

Code for this patient as follows, says Adams:

• 331.0 (Alzheimer’s disease);
• 294.11 (Dementia in conditions classified elsewhere with behavioral disturbance);
• 428.0 (Congestive heart failure);
• 787.20 (Dysphagia, unspecified);
• 788.34 (Incontinence of urine without sensory awareness);
• V40.31 (Wandering in diseases classified elsewhere); and
• V66.7 (Encounter for palliative care).

All of the conditions coded here are indicated as key co-morbid conditions defined in the Palmetto GBA LCD related to Alzheimer’s disease, a useful reference even if you are not served by Palmetto, Adams says.

CHF or COPD both lead to impairments in cardio-respiratory function such as orthopnea, dyspnea, wheezing, chest pain, plus structural impairments in coronary arteries or bronchial tree (more associated with COPD) which lead to activity limitations, Adams notes.

Once a person reaches stage 7 activity limitations, he most likely will have a life expectancy of 6 months or less, Adams says. This is true even when these limitations may be caused by the co-morbid or secondary conditions rather than the primary diagnosis -- Alzheimer’s disease in this case. In Mr. K’s situation, the dysphagia, and incontinence add to further deterioration in his condition and the need for more resources to care for this patient.

In this scenario, Mr. K has reached stage 7a on the FAST scale with his limited speech and is also experiencing limitations in ambulation perhaps related to his Alzheimer’s disease but exacerbated with his CHF, Adams points out.

The wandering code further describes the greater needs required to care for him and supports the behavioral problems, Adams says.

Bottom line: Including the co-morbidities that impact his terminal disease provides a much clearer view of Mr. K’s true hospice appropriateness and decline.

Hospice agencies should involve their hospice medical director in determining which co-morbid or secondary conditions directly impact the patient’s terminal diagnosis versus which conditions may be present, but are not related to the terminal diagnosis, Adams advises.