Home Health ICD-9/ICD-10 Alert

Do you know when your focus of care comes second?

Over the last two years, the Centers for Medicare & Medicaid Services has made it clear that your hospice diagnosis coding requires greater detail than was accepted in the past. Gone are the days when you could list a single code describing your patient’s terminal condition. And once-common diagnoses like adult failure to thrive and debility no longer make the grade as principal diagnoses.

With CMS’s focus on hospice coding, it’s more important than ever that you comply with the Official Guidelines for Coding and Reporting. You also likely need to expand your coding to cover all the diagnoses and conditions that are contributing to the terminal condition that makes each patient eligible for the Medicare Hospice Benefit.

Know What’s Required

The diagnosis codes you report should provide an updated, accurate picture of the patient’s health status, said Judy Adams, RN, BSN, HCS-D, HCS-O, with Adams Home Care Consulting in Asheville, N.C. Your coding should support the patient’s need for hospice. The diagnosis codes your report should describe the patient’s terminal condition and life expectancy of six months or less if the conditions follow their usual trajectory, Adams said.

Remember, your hospice agency is responsible for not only identifying, but paying for all medications and treatments needed for the palliative care of the hospice patient, Adams said in the recent Eli-sponsored audioconference Hospice Coding Update 2014.

Understand the Basic Rules for Coding

The first step in coding accurately is to know the basic requirements of hospice coding. To begin with, you needn’t report every condition the hospice patient has. You should only report diagnoses that are relevant or contribute to the reason the patient requires hospice care, Adams said. The diagnoses you report should all contribute to the patient’s terminal illness.

While you can collect information about your hospice patient, only the physician can diagnose the patient. The physician should establish or verify all the diagnoses you report, Adams said. Be certain the diagnoses you report are documented in a copy of the physician summary in the medical record or verified with the physician via phone or fax. You must have a source document that shows the physician determined the diagnosis.

“The interdisciplinary team and especially the hospice medical director should have a role in determining which diagnoses are related to the terminal illness and which are not related,” 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. “Increased scrutiny by CMS means that there should be clear documentation why conditions were determined to be unrelated.” 

Look to Official Guidelines 

While inadequate hospice coding has squeaked by for years, CMS had made clear that it’s no longer acceptable. Your coding must be in compliance with the official coding guidelines, Adams cautions. The guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM manual.

The official coding guidelines are applicable to all health care settings, unless otherwise indicated, Adams said. The Health Insurance Portability and Accountability Act (HIPAA) requires you to adhere to these guidelines when assigning ICD-9 diagnosis codes. To code accurately for your hospice patients, you’ll need to understand the coding conventions and guidelines and how to use the code book.

The general coding guidelines provide instruction for coding a number of special situations, such as:

• Use of signs and symptoms codes
• Multiple coding for a single condition
• Acute and chronic conditions
• Late effects

Symptom coding and multiple coding situations are of special interest to hospice providers. 

Multiple mandatory coding or the etiology/manifestation convention requires you to list two codes for certain conditions. These conditions require one code that describes the underlying etiology and a second code that describes the manifestation. The underlying condition must be sequenced first, followed by the manifestation code, Adams said.

For example: If your patient has dementia without behavioral disturbance due to Parkinson’s disease, you would list the Parkinson’s code first, followed by the dementia code:

• 332.0 (Parkinson’s disease, NOS)
• 294.10 (Dementia in conditions classified elsewhere without behavioral disturbance)

ICD-10: If you were coding for this patient in ICD-10, you would report:

G20 (Parkinson’s disease)
F02.80 (Dementia in other diseases classified elsewhere without behavioral disturbance)

When you look up manifestation codes in your coding manual, you’ll see that the etiology code has a “use an additional code” note. The manifestation code often contains “in diseases classified elsewhere” in the code title and a “code first the underlying condition” note following the code, Adams said. That means you can’t list these codes first or as the principal diagnosis code, even if the manifestation is the focus of your care. 

Bottom line: Manifestation codes must be used in conjunction with an underlying condition code and they must be listed following the underlying condition, Adams said.

Symptom codes describe patient problems, not diseases, Adams said. Instead of listing a symptom code, you should code the condition if it’s a new diagnosis, an exacerbation of an existing diagnosis, or you are treating multiple aspects of a chronic condition, she said.

Only report a symptom code when there is no definitive diagnosis that can be identified or determined by the physician, Adams said. And never assume a patient has a particular disease or condition based on symptoms alone.

When you have a definitive diagnosis do not code symptoms that are integral to that diagnosis, Adams reminded. For example: if your patient has a diagnosis of congestive heart failure, you don’t need to list an additional code to indicate that she has edema.

Note: To order a CD or transcript of Adams’ audioconference, visit www.audioeducator.com/hospice/hospice-coding-2014-02-18-14.html.