Home Health ICD-9/ICD-10 Alert

CMS asks for your input about terminal illness, related conditions definitions.

Your hospice coding is drawing more and more scrutiny. Make certain your staff isn’t making one of these common coding errors.

The Centers for Medicare & Medicaid Services proposed rule for hospice payment in fiscal year 2015 underscores the agency’s expectations for more detailed hospice diagnosis coding. From requesting comments on coding-related definitions to announcing upcoming coding edits, the proposed rule doesn’t let coders off the hook.

“CMS plans to continue to apply pressure to hospice to code more completely,” says Judy Adams, RN, BSN, HCS-D, HCS-O, with Adams Home Care Consulting in Asheville, N.C.

Weigh in on Terminal Illness and Related Conditions

Hospice providers still feel uncertain about the terms “terminal illness” and “related conditions, CMS notes in the proposed rule. As a result, CMS asks providers to submit comments on their proposed definitions.

CMS’s proposal for a terminal illness definition is: “Abnormal and advancing physical, emotional, social and/or intellectual processes which diminish and/or impair the individual’s condition such that there is an unfavorable prognosis and no reasonable expectation of a cure; not limited to any one diagnosis or multiple diagnoses, but rather it can be the collective state of diseases and/or injuries affecting multiple facets of the whole person, are causing progressive impairment of body systems, and there is a prognosis of a life expectancy of six months or less.”

CMS’s proposal for a related condition definition is: “Those conditions that result directly from terminal illness; and/or result from the treatment or medication management of terminal illness; and/or which interact or potentially interact with terminal illness; and/or which are contributory to the symptom burden of the terminally ill individual; and/or are conditions which are contributory to the prognosis that the individual has a life expectancy of 6 months or less.”

“Although I think CMS is very set in its definition of terminal illness and related conditions, it is good to see that the proposed rule does urge hospice programs to provide input into their definition of these two key terms,” Adams says. “My hope is that many hospices will submit input for an improved definition acceptable to all to define what a terminal illness is and also a clear definition of related condition.”

“I like the definition of terminal illness that Medicare has proposed, however I believe the definition of related condition is way too broad, in effect capturing every co-morbidity as a related condition,” says Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates, LLC, CoDR—Coding Done Right and Code Pro University in Denton, Texas. “That’s a problem since hospices are expected to cover the medications and treatments for all related conditions under the per diem rate.” 

“The language ‘…which interact, or potentially interact with terminal illness,’ is especially problematic,” Selman-Holman says. “Take for an example, a pre-existing diagnosis like diabetes. It may not be directly related to the terminal illness in any way, but certainly could ‘potentially interact’ with the terminal illness since diabetes affects the body systemically. As the terminal condition worsens the patient may not be able to handle giving their own insulin due to mental or physical deterioration. Is the hospice expected to then make visits to teach a caregiver or administer the insulin?”

Bone Up on Coding Guidelines

The proposed rule reminds home health agencies that diagnosis reporting on hospice claims must adhere to ICD-9-CM coding conventions and guidelines, which apply to both the principal diagnosis and reporting of any additional diagnoses, points out Denise Caposella, CPC, with Acevedo Consulting Incorporated in Delray Beach, Fla.

Under the proposed rule, beginning Oct. 1, 2014, claims will be returned to the provider when they list a non-specific symptom diagnosis as the principal hospice diagnosis in section III. To avoid being caught up in this reimbursement-delaying situation, hospices must avoid non-specific symptom diagnoses and code at the highest level of specificity, Caposella says.

The proposed rule also reminds that CMS’s Hospice Claims Processing manual (Pub 100-04, chapter 11) requires hospice claims to include additional/other diagnoses as required by ICD-9-CM coding guidelines. That means reporting all coexisting or additional diagnoses related to the terminal illness and related conditions on the hospice claim. 

“Hospices will need to have a good understanding of ICD-9-CM coding conventions and guidelines and ensure additional diagnoses related to the terminal illness and related conditions are reported,” Caposella says.

Take Note of These Dicey Diagnoses

Also beginning Oct. 1, 2014, the proposed rule indicates CMS’s plans to return to provider any claims with “debility” or “adult failure to thrive” in the principal diagnosis field. “‘Debility’” and ‘adult failure to thrive’ do not provide enough information to accurately describe Medicare hospice beneficiaries and the conditions that hospices are managing,” CMS says.

Dementia diagnoses also remain under fire in the 2015 proposed rule. “Many of the codes relating to dementia manifestations found under the ICD-9-CM classification, ‘Mental, Behavioral, and Neurodevelopmental Disorders,’ are not appropriate as principal diagnoses because of etiology/manifestation guidelines or sequencing conventions under the ICD–9–CM Coding Guidelines,” CMS says. “Hospices need to pay particularly close attention to the various coding and sequencing conventions found within The Official ICD-9-CM Guidelines for Coding and Reporting when reporting dementia diagnoses on hospice claims,” Caposella cautions.

For example: CMS reports that among the top 20 diagnoses for 2012, at numbers 10 and 19, are 294.10 (Dementia in conditions classified elsewhere without behavioral disturbance) and 294.11 (Dementia in conditions classified elsewhere, with behavioral disturbance), respectively. “Those two codes are manifestation codes, meaning they cannot be coded as primary and the underlying condition must be coded first,” Selman-Holman says. “Those two codes appearing on this list is illustrative of the problem of not knowing and following coding guidelines and conventions.”

In addition, the code 294.8 (Other persistent mental disorders due to conditions classified elsewhere) appears as number 16 on the list of most common primary diagnoses. “Hospices are most likely using that code to indicate dementia, NOS when there is no further documentation of the cause of the dementia. The problem is that these statistics represent 2012 claims and there were new codes introduced in October 2011 for dementia, NOS (294.20 and 294.21). This illustrates the importance of keeping updated with code changes,” Selman-Holman reminds.

“Despite nearly three years of telling hospices that they do not believe debility and adult failure to thrive are appropriate principal diagnoses for terminally ill patients, the rule notes that these two diagnoses continue to be among the most common hospice principal diagnoses at 14 percent and when combined with dementia and Alzheimer’s, the percentage of claims with these combined principal diagnoses climbs to 30 percent for 2013,” Adams points out.

Bottom line: “The 2015 rule is a mirror of the 2013 and 2014 rules with its emphasis on coding all co-morbid and coexisting conditions, following the official coding guidelines and staying away from those unspecified codes as principal diagnoses,” Adams says. “Given all of the new regulatory and quality requirements facing hospice and the continued emphasis that hospice should be responsible for paying for everything at the end of life, it will continue to create challenges for hospice to survive.”

Note: Read the entire final rule at www.gpo.gov/fdsys/pkg/FR-2014-05-08/pdf/2014-10505.pdf. Share your comments on the final rule with CMS at www.regulations.gov by 5 p.m. on July 1, 2014. Follow the ‘‘Submit a comment’’ instructions provided at the link.