Home Health ICD-9/ICD-10 Alert

Published on Sun Nov 20, 2011 PDF

New neoplasm codes don't make the grade.

The 2012 ICD-9 updates brought a plethora of changes for home health. And there are some unpleasant surprises included in the new list of case mix codes.

There are several new codes that have been added to the case mix list, but some codes expected to be on the list haven't made the cut, according to data in the July PPS Grouper released August 16 and available here: https://www.cms.gov/HomeHealthPPS/05_CaseMixGrouperSoftware.asp.

Most surprising is that of the 40 new five-digit codes in category 173.x (Other and unspecified malignant neoplasm of the skin), only ten have been included in the case mix additions.

Category 173 is a case mix diagnosis in the Neoplasm category, but CMS only included ten of the new codes in the July 2011 PPS grouper update. The included codes all list fifth digit "9," meaning "other specified," which means there would be no case mix points for skin cancer other than melanoma (coded with 172 codes, already case mix codes), points out 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. "Fifth digit '0' means unspecified so if the physician documentation says simply 'skin cancer,' there would be no case mix points," she says.

In addition, if the physician specified basal cell skin cancer or squamous cell skin cancer, there also would be no points, Selman-Holman says. New fifth digits added to this category differentiate between basal cell carcinoma and squamous cell carcinomas of the skin. But "CMS's choice to include fifth digit '9' is a major problem because that '9' means only 'other specified' skin cancers are included as case mix," she says. "If you search for non-melanoma skin cancers, the only types mentioned are basal cell and squamous cell, so CMS has effectively deleted a case mix code without regulatory change." Stay tuned to see if CMS makes a change to correct this.

Dementia: New codes 294.20 (Dementia, unspecified, without behavioral disturbance) and 294.21 (Dementia, unspecified, with behavioral disturbance) offer new options for reporting dementia not related to another disease process like Alzheimer's. These codes will replace 2011 code 294.8 (Dementia NOS).

The 2011 code for dementia, NOS is 294.8 and is a case mix code. Deleting the inclusion note for Dementia, NOS from 294.8 and moving it to 294.2x seemed like a welcome change, but the 294.2x codes are not on the case mix list, "So once again, CMS has deleted a case mix code," Selman-Holman says.

Thalassemia: There are six new five-digit codes for specific forms of thalassemia replacing current code 282.49 (Other thalassemia). Five of these more specific codes will be case mix diagnoses. But, while category 282 (Hereditary hemolytic anemias) is already in the Blood Disorder case mix category, 282.40 Thalassemia, unspecified was not included in CMS's grouper update as a case mix code.

Tip: Be sure to ask the physician for more information if "thalassemia" is all he includes in the medical record.

Pancytopenia: Three more specific five-digit codes related to pancytopenia at 284.1x (Pancytopenia) have been added to case mix since category 284 in the Blood Disorder category.

Fractures: Two new codes, 808.44 (Multiple closed pelvic fractures without disruption of pelvic circle) and 808.54 (Multiple open pelvic fractures without disruption of pelvic circle) along with revised codes 808.43 (Multiple closed pelvic fractures with disruption of pelvic circle) and 808.53 (Multiple open pelvic fractures with disruption of pelvic circle) will be case mix diagnoses in the Ortho 1 category since all of the 808 (Fracture of pelvis) category is case mix.