Eli's Hospice Insider

Debility, Adult Failure To Thrive, Dementia codes and more will get your claim kicked back to you under new edits.

You must rid your hospice claims of banned diagnoses, or you’ll shortly pay the price in reduced cash flow.

The Centers for Medicare & Medicaid Services finalized plans to ban Debility (799.3, 780.79/R53.81) and Adult Failure to Thrive (783.7/R62.7) in previous payment rules. Now CMS has issued marching orders to the Medicare Administrative Contractors to put the edits in place Oct. 1, as previously scheduled.

“The principal diagnosis reported on the claim should be the diagnosis most contributory to the terminal prognosis,” CMS stresses in CR 8877 issued Aug. 22. “Both ‘debility’ and ‘adult failure to thrive’ are considered nonspecific, symptom diagnoses according to ICD-9-CM/ICD-10-CM Coding Guidelines.”

Plus: “Hospices are not to report dementia codes, classified as unspecified or which have a ‘code first’ sequencing convention, as principal hospice diagnoses on the hospice claim,” CMS instructs in the transmittal. “The dementia codes under the 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/ICD–10–CM Coding Guidelines.” Those include 294.10/F02.80, (Dementia in diseases classified elsewhere without behavioral disturbance) and 294.11/F02.81 (Dementia in diseases classified elsewhere with behavioral disturbance).

In addition to the debility, AFTT and dementia codes, the CR includes a table of 35 dementia and other manifestation codes that will result in a returned claim, if listed as the primary diagnosis.

Do this: “The underlying condition must be coded as the principal diagnosis and the aforementioned dementia conditions would be appropriate as secondary diagnoses,” CMS says.

“While most hospice providers have been working to eliminate use of ‘debility’ or ‘failure to thrive’ as a principal diagnosis in recent years, hospices must now take similar steps to eliminate use of the other codes that, if used as a principal diagnosis, will result in the hospice claim being returned for a more appropriate principal diagnosis,” the National Association for Home Care & Hospice advises.

Take These 5 Steps To Prepare For When Edits Hit

Consider taking these steps to prepare for the coding change, NAHC counsels in its member newsletter:

1. Identify existing patients for which your hospice currently uses a non-allowed code as the principal diagnosis. Encourage the hospice team, with involvement of staff with training in proper ICD-9-CM coding principles, to discuss alternative diagnoses that might more appropriately represent the diagnosis that is most contributory to the patient’s terminal prognosis.

2. While it is the hospice physician that identifies the diagnoses that establish a six-month prognosis, staff trained in coding principles are permitted to select the appropriate diagnosis, according to CMS.

3. Have someone on staff or contracted who is trained in ICD-9-CM coding requirements and who receives continued education for ICD-10-CM.

4. Consider what, if any, additional information your intake/admission team needs to collect in order for the physician to have enough information to best determine the patient’s principal and related diagnoses.

5. CMS reiterates the requirement to list all of a patient’s pertinent diagnoses on the claim. “All of a patient’s coexisting or additional diagnoses that are related to the terminal illness and related conditions should be reported on the hospice claim,” the agency says in a Medicare Claims Manual addition included in the transmittal.

Make sure all of a patient’s coexisting or additional diagnoses that are related to the terminal illness and related conditions are going onto the hospice claims, NAHC urges.

Note: The transmittal is at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3032CP.pdf.