Home Health ICD-9/ICD-10 Alert

Look to the 438.xx codes for complications.

The Centers for Medicare & Medicaid Services has made clear it’s not happy with the state of diagnosis coding for hospice patients. Thankfully, you have an opportunity to improve your accuracy before your reimbursement takes a hit.

Problem: According to the 2014 Hospice Wage Index and Payment Rate Update published in the Aug. 7 Federal Register, in 2012, the ninth most reported principal hospice diagnosis was 436 (Acute but ill-defined, cerebrovascular disease). CMS lists this code as indicating “CVA/Stroke,” but that hasn’t been the code description for this code since 2004, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR — Coding Done Right in Denton, Texas.

This code is “not a good choice at all for a terminally ill patient,” Selman-Holman says.

Get the Right Codes for Stroke

Instead, look to the 438.x (Late effects of cerebrovascular disease) codes, Selman-Holman says. The complications of the stroke are the conditions that really explain why the patient is terminally ill. These codes include:

• 438.0 (Late effects of cerebrovascular disease; cognitive deficits);
• 438.2x (Late effects of cerebrovascular disease; hemiplegia/hemiparesis);
• 438.3x or .4x (Late effects of cerebrovascular disease; monoplegia);
• 438.5x (Late effects of cerebrovascular disease; other paralytic syndrome) — include a second code to specify locked-in state (344.81) or quadriplegia (344.00-344.09);
• 438.82 (Late effects of cerebrovascular disease; dysphagia) — include a second code to specify the type of dysphagia such as 787.20 (Dysphagia, unspecified); and
• 438.89 (Other late effects of cerebrovascular disease); — include a second code to specify the late effect such as 780.03 (Persistent vegetative state).

Don’t Miss Co-Morbidities

Once you’ve selected the code(s) that describe your patient’s CVA late effects, you’ll need to consider whether he has any stroke co-morbidities that you should list as well. You should include diagnosis codes for co-morbidities when they impact the plan of care.

When considering whether to code for a co-morbidity, consider the patient’s palliative performance scale score. Patients who with a palliative performance scale score of 40 may be more likely to be covered by hospice, Selman-Holman says.

A Palliative Performance Scale (PPS) of 40 is composed of two elements:

a) Degree of ambulation — Mainly in bed
b) State of consciousness — Either fully conscious or drowsy/confused

Depending on your patient’s condition, if he scores a 40, you may want to include some of the following diagnosis codes:

• V49.84 (Bed confinement status)
• V46.3 (Wheelchair dependence)
• 780.01 (Coma)
• 780.02 (Transient alteration of awareness)
• 780.03 (Persistent vegetative state)
• 780.09 (Alteration of consciousness; other) which includes drowsiness, semi-coma, and somnolence

Another indicator that a patient who has suffered a stroke is likely to be eligible for hospice is inability to maintain hydration and caloric intake with one of the following:

• Weight loss
• Low serum albumin
• Pulmonary aspiration

Depending on your patient’s condition, you may want to include some of the following diagnosis codes, Selman-Holman says:

• 783.21 (Abnormal loss of weight) also include a code for BMI (V85.xx)
• 783.0 (Anorexia)
• 273.8 (Other disorders of plasma protein metabolism) for low serum albumin
• 934.8 (Foreign body in trachea, bronchus, and lung; other specified parts)
• 507.0 (Aspiration pneumonia)

Coding scenario: Your patient has cognitive deficits related to a CVA with feeding difficulties and 25 percent loss of body weight. She also has transient loss of consciousness and pseudobulbar affect. This patient has a do not resuscitate (DNR) status.

List the following codes for this hospice patient, Selman-Holman says:

• 438.89 (Other late effects of cerebrovascular disease);
• 783.3 (Feeding difficulties and mismanagement);
• 783.21 (Abnormal loss of weight);
• 310.81 (Pseudobulbar affect);
• 438.0 (Late effects of cerebrovascular disease; cognitive deficits); and
• 780.02 (Transient alteration of awareness).

It’s important to make certain you’re listing all the appropriate diagnosis codes for your patients. All of the codes listed above combine to indicate what’s going on with the patient, Selman-Holman says. If you have them all listed on your claim form, then whoever is reviewing your claim can see that this patient has had a CVA, she has feeding difficulty, and abnormal loss of weight. She has had some problems with her transient awareness, her cognitive status is strange, and she also has a pseudobulbar affect which causes her to laugh or cry for no reason.

Bottom line: Coding thoroughly for your hospice patients will help improve your patient data today, and could help safeguard your reimbursement in the future.