Home Health ICD-9/ICD-10 Alert

Make sure you know these key definitions.

The proposed rule for 2014 hospice payment rates gives two popular primary hospice diagnoses the axe. No longer can you list “debility” (799.3) or “adult failure to thrive” (783.7) as the primary diagnosis codes on hospice claims. Make sure you’re following this new guidance or you can expect returned claims.

No New Rules?

“This section is a clarification of existing ICD–9–CM coding guidelines. No proposals are being made in this proposed rule with regards to diagnosis coding,” the Centers for Medicare & Medicaid Services says in the proposed rule. But coding experts say the instruction that that debility and adult failure to thrive cannot be coded as primary goes counter to previous hospice coding instruction including an Adult Failure to Thrive in hospice Local Coverage Decision (LCD) from HHH Medicare Administrative Contractor Palmetto GBA.

“Over time … there has been a notable shift in the most commonly reported hospice diagnoses from cancers to non-cancer terminal illnesses, such as ‘debility’ and ‘adult failure to thrive,’ which are considered to be nonspecific, symptom diagnoses according to ICD–9–CM Coding Guidelines and are under the ICD–9–CM classification of ‘Symptoms, Signs and Ill-defined Conditions,”’ CMS says.

“Codes under the classification, ‘Symptoms, Signs, and Ill-defined Conditions,’ are not to be used as principal diagnosis when a related definitive diagnosis has been established or confirmed by the provider,” CMS continues.

Look to Other Conditions

All this appears to make coding for Hospice patients increasingly complex. But fortunately, CMS also provides some guidance on coding when non-specific, symptom diagnoses are present, said Kristy Wright RN, BSN, MBA, FAAN, Director with Hamden, Conn.-based Simione Healthcare Consultants. 

“‘Debility” and ‘adult failure to thrive,’ … are the result of multiple primary conditions that contribute to the terminal decline. If any or all of these multiple primary conditions have been or are being treated or managed by a health care provider, or if medications have been prescribed for the patient to treat or manage any or all of these multiple primary conditions, we believe that these conditions meet the criteria of being established and/or confirmed by the beneficiary’s health care provider,” CMS says.

As a result, the principal diagnosis you list should be the diagnosis most contributory to the terminal condition, said Wright in a post on Simione’s website.

Prepare for a New Approach

The first step to correcting your hospice coding to follow this new guidance is education. And that doesn’t start and stop with coders. Medical directors need to be educated on the new directive from CMS, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR — Coding Done Right in Denton, Texas. “AFTT and debility have been too easy for them for too long,” she says.

Bottom line: In the proposed rule, CMS clarifies that “debility” and “adult failure to thrive” should not be used as principal hospice diagnoses on the hospice claim form. “When reported as a principal diagnosis, these would be considered questionable encounters for hospice care, and the claim would be returned to the provider for a more definitive principal diagnosis.”

You could still include “debility” and “adult failure to thrive” as other, additional, or coexisting diagnoses, but the “principal diagnosis listed should be determined by the certifying hospice physician(s) as the diagnosis most contributory to the terminal condition,” CMS says.

And, when there are two or more interrelated conditions that potentially meet the definition of principal diagnosis, “either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise,” CMS says.

Note: Read the proposed rule here: www.gpo.gov/fdsys/pkg/FR-2013-05-10/pdf/2013-10389.pdf