Home Health ICD-9/ICD-10 Alert

You may be surprised at the diagnoses CMS wants you to report.

Up until recently, coding for hospice patients didn’t have the level of detail required for home health patients. But the Centers for Medicare & Medicaid Services have made clear they expect more than just the terminal diagnosis on your hospice claims. Unfortunately, just how much they want isn’t entirely clear.

Comorbidity Confusion

You know you need to report the terminal diagnosis, but which of your patient’s other conditions need to be included on the claim? CMS’ hospice claims processing manual requires that hospice claims include other diagnoses “as required by ICD-9-CM Coding Guidelines,” said 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. In recent months, CMS has put some weight behind this requirement, including medical review, denials, and future plans for a hospice case-mix system.

But while CMS seems to consider coexisting conditions, comorbidities, and other diagnoses one and the same, at least one home care MAC uses the term “comorbidities” to mean unrelated diagnoses, Selman-Holman said during the session “Determining Diagnoses Related to Terminal Illness” at the 2013 National Association for Home Care & Hospice annual meeting in Washington, D.C. Both NAHC and the National Hospice and Palliative Care Association have requested clarification from CMS on this discrepancy, she said.

In its proposed rule for 2014 hospice payment rates published in the May 10 Federal Register, CMS says “Clinically, related conditions are any physical or mental conditions that are related to or caused by either the terminal illness or the medications used to manage the terminal illness.”

“Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis, all services would be considered related,” CMS continues. “It is also the responsibility of the hospice physician to document why a patient’s medical needs would be unrelated to the terminal prognosis.”

So CMS appears to be moving toward the position that everything is related, Selman-Holman said. And if it’s not related, you’ll need to explain why it’s not related.

Look to IDG to Make the Call

At this point, you’re probably thinking something along the lines of “If I code all of those things, I have to cover all of those things in the hospice per diem rate,” Selman-Holman said. That’s what CMS expects, she said. Sometimes, getting claims from other providers for a patient receiving hospice services isn’t what CMS wants.

When it comes to deciding which diagnoses are related and which are unrelated, you should look to your hospice interdisciplinary group, Selman-Holman said. “Information about related and unrelated diagnoses should already be included as part of the plan of care, and determined by the hospice interdisciplinary group (IDG).” The IDG makes the call for the following reasons, Selman-Holman said:

• The hospice conditions of participation (CoPs) at 418.54(c)(2) require that the comprehensive assessment include “complications and risk factors that affect care planning.”
• The CoPs at 418.56(e)(4) require that the hospice IDG “provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.”
• The existing standard practice for hospices is to include the related and unrelated diagnoses on the patient’s plan of care in order to assure coordinated, holistic patient care and to monitor the effectiveness of the care that is delivered.

“You bill monthly, so you’ll have to consider this each month,” Selman-Holman said.

To help decide which diagnoses are related and which are unrelated, consider that for hospice patients you could interpret “other diagnoses” as additional conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, or increased nursing care and/or monitoring, Selman-Holman said. Unrelated diagnoses could include pre-existing conditions or other comorbidities that do not impact the plan of care, she said.

Scenario: Your patient’s terminal diagnosis is cancer of the lung. The patient has required insulin to manage his diabetes for several years. The patient is too weak and confused to take his insulin safely and his caregivers are overwhelmed. Home health will see the patient for his diabetes and use of insulin.

In this case, the patient’s diabetes is unrelated to his terminal diagnosis, Selman-Holman said. So, you wouldn’t include a diabetes code on the claim for this patient. However, you should list the diagnosis in the body of the plan of care (POC) because you need to coordinate care for it.

On the other hand: If the patient had pancreatic cancer, you would have a hard time arguing the diabetes was unrelated, Selman-Holman said.

Tip: When it comes to listing the unrelated diagnoses on the POC, “my feeling is that you don’t need to include a code, just list the diagnosis,” Selman-Holman said.