Home Health ICD-9/ICD-10 Alert

Always follow coding guidelines to ensure accuracy.

The Centers for Medicare & Medicaid Services has taken an interest in your Hospice dementia coding. Make certain you’re following the right guidance when coding these diagnoses or you could find your reimbursement suffering in the future.

CMS has noticed a "concerning trend" of codes from ICD-9 Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders among the top twenty claims-reported principal hospice diagnoses. Several codes from this chapter are being reported as principal hospice diagnoses when ICD–9 coding guidelines specify that they should not be used as principal diagnoses at all, CMS says in the proposed 2014 Hospice Wage Index and Payment Rate Update.

The problem: Some of these dementia codes are manifestation codes. When a condition has both an underlying etiology and multiple body system manifestations caused by the etiology, ICD-9 requires you to list two codes.

So, when reporting a manifestation code, you must first list the underlying condition and then follow it with the code for the manifestation.

Follow these Coding Clues

When ICD-9 coding guidelines require you to list an etiology/manifestation pair, you’ll find instructions in your coding manual that help guide your sequencing. When you look up the etiology code, you’ll see a note advising you to ‘‘use additional code’’ to describe any manifestations. And when you look up the manifestation code you’ll see a ‘‘code first’’ note reminding you to list the underlying condition first.

For example: Two codes CMS lists in the top twenty principal hospice diagnoses for Fiscal Year 2012 are clearly marked as manifestation codes in your ICD-9 manual. ICD-9 codes 294.10 (Dementia in conditions classified elsewhere without behavioral disturbance) and 294.11 (Dementia in conditions classified elsewhere with behavioral disturbance) are both preceded by the instructional note at subcategory 294.1 (Dementia in conditions classified elsewhere) to "Code first any underlying physical condition."

Despite this instruction in the coding manual, 294.10 was the tenth most popularly reported principal hospice diagnosis in FY 2012 and 294.11 ranked 19th.

Another clue: In most cases, manifestation codes include the wording "in diseases classified elsewhere" or "in conditions classified elsewhere" right in the code title, CMS points out. When you see this wording in the code title, you know you’re looking at a manifestation code. And "‘In diseases classified elsewhere’ or ‘in conditions classified elsewhere’ codes are never permitted to be used as first listed or principal diagnosis codes and they must be listed following the underlying condition," CMS reminds.

Watch Use of Other Dementia Codes

Two other dementia diagnoses also made the top 20 list: 290.0 (Senile dementia, uncomplicated) and 294.8 (Other persistent mental disorders due to conditions classified elsewhere). But these codes aren’t great choices for hospice patients, experts agree.

"There is a note at the top of the 290 classification that states to code first the associated neurological condition," says Judy Adams, RN, BSN, HCS-D, HCS-O, with Adams Home Care Consulting in Asheville, N.C. "If the associated neurological condition is not listed, the dementia would be coded as 290.0."

But listing 290.0 as the principal diagnosis for a patient with senile dementia probably isn’t your best choice, 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. "I’d want better information so I could use a different 4th digit," she says.

But you can only code the information that is given to you by the physician, Adams reminds. "In the case of 290.4 (Vascular dementia), there is a note to use an additional code to identify cerebral atherosclerosis (437.0), but this can only be coded if the information is provided." Sometimes a physician will list another condition as associated with vascular dementia such as parkinsonism, she says. But other times he may not mention another associated condition, so vascular dementia is the only information given.  

Prior to Oct. 1, 2011, 294.8 was the code to list for Dementia, NOS. But this code is no longer appropriate for reporting dementia, Selman-Holman says. Instead, look to 294.20 (Dementia, unspecified, without behavioral disturbance).

The new Dementia, NOS subcategory also includes 294.21 (Dementia, unspecified, with behavioral disturbance), says Adams. And remember to use additional code V40.31 (Wandering in diseases classified elsewhere) where applicable.

Tricky: There is a slight wording difference between the designated manifestation codes "dementia in conditions classified elsewhere" and 294.8’s which states "other persistent mental disorders due to conditions classified elsewhere," Adams says. Also, at 290.4x and 294.8 the note is to ‘use an additional code to identify _____’ rather than ‘code first’ which is the note seen at manifestation codes."

Take Care with Alzheimer’s, Parkinson’s, and Stroke

The data gathered for FY 2012 also found that patients with a principal hospice diagnosis of a dementia most often had secondary diagnoses of Alzheimer’s disease, Parkinson’s disease, or stroke, CMS says.

While some dementia codes may be acceptable as principal diagnoses others do have manifestation/etiology or sequencing conventions, CMS says. "Therefore, it is imperative that hospice providers follow ICD–9–CM coding guidelines and sequencing rules for all diagnoses and pay particular attention to dementia coding as there are dementia codes found in more than one ICD–9–CM classification chapter and there are multiple coding guidelines associated with these dementia conditions."

For example: If you’re coding for a patient with Alzheimer’s dementia as his principal diagnosis, you’ll need to list 331.0 (Alzheimer’s disease) first and follow with a 294.1x code.

Confusing: There’s a note at code category 331 (Other cerebral degenerations) that says, "Use additional code, where applicable, to identify dementia," Selman-Holman says. "With some of these codes, people get confused because they think, ‘Well, they have Alzheimer’s, of course they have dementia. So why do I have to code dementia?’ You still have to code the dementia because the dementia code tells you whether they have behaviors or not," she says.

Remember: "In home health or hospice, we cannot use the acute codes from 430-437 if the patient has had a stroke and then has cognitive issues or dementia," Adams reminds. "Instead coders must use the 438.0 (Late effects of cerebrovascular disease; cognitive deficits) code for cognitive disorder associated with late effect of a stroke."

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