ICD10-CM Codes. Hospice Top 20 and let s talk HIS. A Presentation of the Fazzi Coding Academy. December Presented by: Melanie Duerr, RN, MS, ANP

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1 ICD10-CM Codes Hospice Top 20 and let s talk HIS A Presentation of the Fazzi Coding Academy December 2013 Presented by: Melanie Duerr, RN, MS, ANP Lisa Woolery, RN, BSN, BCHH-C Michelle Mantel, MSN, GNP-BC, APRN, BCHH-C, HCS-D, COS-C Susan Tucker, RN, BSN, HCS-D, COS-C

2 ICD10-CM Codes Hospice Top 20 and let s talk HIS. A Presentation of the Fazzi Coding Academy Michelle Mantel, MSN, GNP-BC, APRN, BCHH-C, HCS-D, COS-C Lisa Woolery, RN, BS, BCHH-C Susan Tucker, RN, BSN, HCS-D, COS-C Melanie Duerr, RN, MS, ANP, BCHH-C What level of coding training will we need? Basic ALL STAFF Intermediate CLINICIANS INTAKE BILLING Advanced CODERS ICD-10 Basics Build Versus Buy Do Both! 1

3 Build versus Buy for ICD-10 Staffing? Do Both. BUILD Grow your own, expand current coding staff by minimums of 30% Train with retention and turnover in mind- Consider CAC-Computer Assisted Coding to increase productivity-but be wary, no CAC product will replace the critical thinking of your experienced coders BUY Supplement your current staff with remote as needed coders Buy a team Secure outsourcing partnerships Only buy what you need, Don t commit to a minimum if your team can expand production ICD-10 Basics PLUS- NEW OASIS NEW HOSPICE ASSESSMENT [HIS] OASIS C-1 M1021 Primary Diagnosis EVENS to ODDS M1025 Optional Diagnosis M1023 Other Diagnosis 2

4 Hospice Information Set- [HIS] Completed on admission and discharge Hospice Item Set Admission Draft V Effective July 1, 2014 Hospice Information Set- [HIS] Completed on admission and discharge Hospice Information Set- [HIS] Completed on admission and discharge 3

5 Hospice Information Set- [HIS] Completed on admission and discharge Hospice Information Set- [HIS] Completed on admission and discharge Hospice Information Set- [HIS] Completed on admission and discharge 4

6 Hospice Information Set- [HIS] Completed on admission and discharge PROPOSED RULE HOSPICE ORIGINS Started by Volunteers to care for the dying (palliative) Two key components put into the legislation responsible for the creation of the Medicare hospice benefit (section 122 of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), (97)). Beneficiary being certified as terminally ill Beneficiary electing the hospice benefit The comprehensive hospice assessment must identify the patient's physical, psychosocial, emotional, and spiritual needs related to the terminal illness and related conditions which must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. 5

7 The Medicare hospice benefit requires the hospice to cover all palliative care related to the terminal illness and related conditions. It is often not a single diagnosis that represents the terminal illness of the patient, but the combined effect of several conditions that makes the patient's condition terminal. Unless there is clear evidence that a condition is unrelated to the terminal illness, all services would be considered related. It is the responsibility of the hospice physician to document why a patient's medical needs would be unrelated to the terminal illness. Hospice Trends A growing percentage of beneficiaries with non-cancer diagnoses, including various dementia diagnoses. Significant increases in the use of non-specific, symptom classified diagnoses, such as debility and adult failure to thrive. In FY 2012, both debility and adult failure to thrive were in the top five claims-reported hospice diagnoses and were the first and third most common hospice diagnoses, respectively Over 77 percent of the hospice claims reported only a principal diagnosis. July 27, 2012 FY 2013 Hospice Wage Index notice (77 FR 44242) CLARIFICATION All of a patient's coexisting or additional diagnoses related to the terminal illness or related conditions should be reported on the hospice claims. The hospice benefit covers all care for the terminal illness, related conditions, and for the management of pain and symptoms. Providers should code and report the principal diagnosis as well as all coexisting and additional diagnoses related to the terminal condition or related conditions to more fully describe the Medicare patients they are treating. July 27, 2012 FY 2013 Hospice Wage Index notice (77 FR through 44248) 6

8 CODE CO-MORBIDITIES CMS is actively collecting and analyzing hospice data for evaluation of hospice payment reform methodologies as mandated in section 3132(a) of the Affordable Care Act. Analysis is to adequately account for any clinical complexities a given hospice patient might have as a result of related conditions, these related conditions must be included on the Medicare hospice claim. Based on analysis of preliminary claims data from the first quarter of FY 2013 (October 1, 2012 through December 31, 2012), 72 percent of providers still only report one diagnosis on the hospice claim. General Rules for Other (Additional) Diagnoses For reporting purposes the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring. The UHDDS item #11-b defines Other Diagnoses as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. SYMPTOM CODING Symptoms, Signs, and Ill-defined Conditions, are not to be used as principal diagnosis when a related definitive diagnosis has been established or confirmed by the provider. If the cause of the symptom is known code the cause (disease) Do not code symptoms that are integral to the disease process code the disease only 7

9 DEBILITY Debility is medically defined as: an unspecified syndrome characterized by unexplained weight loss, malnutrition, functional decline, multiple chronic conditions contributing to the terminal progression, and increasing frequency of outpatient visits, emergency department visits and/or hospitalizations. The individual diagnosed with Debility may have multiple comorbid conditions that individually, may not deem the individual to be terminally ill. However, the collective presence of these multiple comorbid conditions will contribute to the terminal status of the individual. DEBILITY Data analysis using FY 2012 claims data for beneficiaries with a reported principal hospice diagnosis of debility, and reported secondary diagnoses, shows that the most common secondary diagnoses reported are; congestive heart failure, coronary artery disease, heart disease, atrial fibrillation, Parkinson's disease, Alzheimer's disease, renal failure, chronic kidney disease, and chronic obstructive pulmonary disease ADULT FAILURE TO THRIVE Adult Failure to Thrive is defined as undefined weight loss, decreasing anthromorphic measurements (MAC), and a Palliative Performance Scale < 40 percent. Associated with multiple primary conditions contributing to physical and functional decline: impaired physical functioning, malnutrition, depression, and cognitive impairment. 8

10 ADULT FAILURE TO THRIVE Data analysis using FY 2012 claims data for those beneficiaries with a reported principal hospice diagnosis of adult failure to thrive, and reported secondary diagnoses, shows that the most common secondary diagnoses reported are: pneumonia, cerebral vascular accident (stroke), atrial fibrillation, heart disease, Alzheimer's disease, congestive heart failure, and Parkinson's disease Mental, Behavioral and Neurodevelopmental Disorders. There are several codes that are frequently reported as principal hospice diagnoses on hospice claims, but are not appropriate principal diagnoses per ICD-9-CM Coding Guidelines. Some of these ICD-9-CM codes are considered manifestation codes. Wherever such a combination exists, there is a use additional code note at the etiology code, and a code first note at the manifestation code. In most cases, these manifestation codes will have in the code title, in diseases classified elsewhere or in conditions classified elsewhere. DEMENTIAS In FY 2012 Four (4) Dementia codes were in the Top 20: #7: Senile Dementia Implies no disease process just old #10: Dementia in Diseases classified elsewhere (no behavioral issues) This is NOT a primary code. Code the condition first (Alzh/Parkinson) #16: Other mental disorders This code is NOT the default for Dementia NOS use 294.2x #19: Dementia in Diseases classified elsewhere (WITH behavioral issues) This is NOT a primary code. Code the condition first (Alzh/Parkinson) 9

11 ICD-10 Basics: Code Structures Category Etiology/Site/Severity Ext. Alpha Numeric A/N A/N A/N A/N A/N Category: Three characters form the code foundation Etiology, manifestation, anatomical site, severity: 3 Characters add detail Extension: 7 th character for visit encounter, sequelae of injuries and external causes. Use placeholder X to preserve location of 7 th digit A: Initial encounter (Initial/In-patient) D: Subsequent encounter (Aftercare) S: Sequelae (Late Effects) ICD-9 to ICD-10 What is Different? ICD-10 Codes have 3 to 7 character placeholders Separate codes for laterality Additional characters for expanded detail (Placeholder X ) Codes that combine etiology and manifestations Codes that combine poisoning and external cause status Codes that combine diagnosis and symptoms into a single code ICD-10 use of the Placeholder X TWO USES! 1. As a 5 th character for certain 6 character codes to allow for further expansion (specificity) of the code without disturbing the 6 th character structure: T56.0X2S Toxic effect of lead, intentional self-harm, sequela 2. As a placeholder for use in codes that are less than 6 characters long that require a 7 th digit: S17.0XXD Crushing injury of larynx and trachea, subsequent encounter The 7 th character (number or letter) must ALWAYS be in the 7 th position. 10

12 Test your knowledge Which of the codes below is a complete ICD-10 code? A. T37.0XX1A B. S72.041D C. M12X.58 D ICD-9 to ICD-10 What is Different? Exclude Notes: Exclude 1 Notes: Not coded here (Do not use together) Exclude 2 Notes: Not included here (May use 2 together if applies) Laterality: Codes for Right, Left and/or Bilateral sites will be available If no Bilateral code is available and condition affects both sides, use a code for right side and a code for left side. ICD-9 to ICD-10 What is Different? DM codes are combined with most DM manifestations: DM Macular Edema: ICD-9= 3 codes , , DM Macular Edema: ICD-10= 1 code: E EXCEPTIONS: DM Toe Ulcer ICD-9: , DM Toe Ulcer ICD-10: E11.621(DM Foot ulcer vs other DM skin ulcer), L97.5 (unspecified (foot), right or left LE, severity) 11

13 ICD-9 to ICD-10 What is Different? MI Codes Change in time frame from 8 weeks to 4 weeks MI NOS: ICD-9 = (up to 8 weeks) ICD-10 = I21.3 (up to 4 weeks) Using the coding book It s a S.N.A.P. START in the Index (Alpha)- use Main Term NEVER stop at unspecified unless no other information (NOS) ALWAYS check in Tabular for further instructions (include and exclude notes) PICK diagnosis that best matches description considering coding conventions What happens to claims that start after September 1 st, 2013? 12

14 Conventions: Punctuation In the Alpha and Tabular section: ( ) Parentheses enclose supplementary words, called nonessential modifiers, that may be present in narrative description without affecting code assignment Anemia (essential) (general) (hemoglobin deficiency) (infantile) (primary) (profound) D64.9. If other terms present see essential modifiers below code in the index. In the Tabular section: [ ] Square brackets enclose synonyms, alternative terminology or explanatory phrases B06 Rubella [German Measles] In the Alpha section: [ ] Brackets in the alpha index indicates code is a manifestation code Conventions: Punctuation In the Tabular section: Colon : Used in the Tabular List after an incomplete term that needs one or more of the modifiers below the colon to make it assignable to that category Also used with both includes and excludes notes Conventions: Punctuation In the Index and Tabular section: Dashes ( - ) Used in the Index at the end of a code to indicate the code is incomplete (go to Tabular to complete): FRACTURE, pathologic; ankle M In the Tabular List a dash after the decimal point indicates an incomplete code: J43 Emphysema Excludes 1: emphysematous (obstructive) bronchitis (J44.-) 13

15 What else do I need to know? Basic knowledge of: Anatomy and physiology Medical terminology Disease processes Alternative terms So is that all? Not Quite! 14

16 Some Examples.! MD must assign diagnoses! Clinician may provide further information to MD to specify/verify code assignment Do NOT code: Probable Suspected Questionable Rule out (Working diagnoses) Code to highest level of specificity CHAPTER 1 Certain Infectious and Parasitic Disease A00-B99 15

17 CODE THIS: UTI DUE TO ECOLI CHAPTER 1-Certain Infectious and Parasitic Disease A00-B99 ICD UTI, site not identified Use additional code to identify the organism 041.4X E. Coli ICD-10CM N39.0 UTI, site not identified Use additional code to identify the organism (B95-B97) B96.20 E. Coli CHAPTER 2- Neoplasms C00-D49 CODE THIS: Lung Cancer2 C34.9Ø Malignant neoplasm of unspecified part of unspecified bronchus or lung CHAPTER 2- Neoplasms C00-D49 CODE THIS: Breast Cancer11 C5Ø.919 Malignant neoplasm of unspecified site of unspecified female breast 16

18 CHAPTER 2- Neoplasms C00-D49 CODE THIS: Pancreatic Cancer13 C25.9 Malignant neoplasm of pancreas, unspecified CHAPTER 2- Neoplasms C00-D49 CODE THIS: Colon Cancer12 C18.9 Malignant neoplasm of colon CHAPTER 2- Neoplasms C00-D49 CODE THIS: Prostate Cancer15 C61 Malignant neoplasm of prostate 17

19 CHAPTER 2- Neoplasms C00-D49 CODE THIS: Bladder Cancer20 C67.9 Malignant neoplasm of bladder, unspecified CODE THIS: Malignant Neoplasm of the breast, female, unspecified site, unspecified breast CHAPTER 2-Neoplasms C00-D49 ICD Malignant neoplasm of the breast, unspecified ICD-10CM C Malignant neoplasm of unspecified site of unspecified female breast Malignant Neoplasm of the breast, female, unspecified site, unspecified breast C Category ICD-10 always starts with a letter and always include 3 out of the possible 7 places Location site in the breast 0-9 Gender Male-2 Female- 1 Laterality 1-right breast 2-left breast 9- unspecified site 18

20 CHAPTER 5 Mental and Behavioral Disorders F00-F99 CODE THIS: Dementia NOS FØ6.8 Other specified mental disorders due to known physiological condition ICD Other persistent Mental Disorders-classified elsewhere ICD-10CM FØ3.90 Other specified mental disorders due to known physiological condition ICD Dementia In Other Diseases with Behavioral disturbances ICD-10CM FØ2.81 Dementia in other diseases classified elsewhere with behavioral disturbance 19

21 CHAPTER 6 Diseases of the Nervous System G00-G99 CODE THIS: Parkinson s Disease G20 Parkinson s Disease14 ICD Parkinson s Disease ICD-10CM G20 Parkinson s Disease G30.9 Alzheimer s Disease ICD Alzheimer s Disease ICD-10CM G30.9 Alzheimer s Disease 20

22 CHAPTER 9 Diseases of the Circulatory System I00-I99 CODE THIS: Heart Disease-Unspecified CHAPTER 9 Diseases of the Circulatory System I00-I99 ICD-9 ICD-10CM Heart Disease Unspecified I51.9 Heart disease, unspecified CHAPTER 9 Diseases of the Circulatory System I00-I CHF ICD-9 ICD-10CM I5Ø.9 Heart failure, unspecified 21

23 CODE THIS: J96.9Ø Respiratory failure18 CHAPTER 9 Diseases of the Circulatory System I00-I ICD-9 Respiratory Failure unspecified ICD-10CM J96.9Ø Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia CHAPTER 10 Diseases of the Respiratory System (J00-J99) 4965 COPD ICD-9 ICD-10CM J44.9 Chronic obstructive pulmonary disease, unspecified Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99) Code This: Pressure Ulcer, Right Heal, Stage 3 22

24 Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99) Pressure Ulcer Right Heel, Stage 4 L Category Sub-Category ICD-10 always starts with a letter and always include 3 out of the possible 7 places Location Laterality 1-right 2-left 9- unspecified Stage Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99) L Pressure ulcer of left lower back, stage 1 L Pressure ulcer of left lower back, stage 2 L Pressure ulcer of left lower back, stage 3 L Pressure ulcer of left lower back, stage 4 L Pressure ulcer of left lower back, unspecified stage L Pressure ulcer of sacral region, stage 1 L Pressure ulcer of sacral region, stage 2 Chapter 14: Diseases of Genitourinary System (N00-N99) Code This: End Stage Renal Disease 23

25 Chapter 14: Diseases of Genitourinary System (N00-N99) ICD-9 ICD-10CM End Stage Renal Disease N18.6 End stage renal disease Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96) Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99) Chapter 18, Signs and Symptoms and Abnormal Clinical and Laboratory Findings, NEC (R00-R99) CODE THIS: Debility, unspecified 24

26 Chapter 18, Signs and Symptoms and Abnormal Clinical and Laboratory Findings, NEC (R00-R99) ICD-9 ICD-10CM Debility, unspecified R62.7 Adult failure to thrive Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88) Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88) DEFAULTS: Fractures not specified as Open or Closed are: CLOSED Fractures not specified as Displaced or Non-Displaced: DISPLACED 25

27 Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88) CODE THIS: Fractured Right Femur Shaft Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88) ICD-9 ICD-10CM V54.15 M1024: S72.301D Unspecified fracture* of shaft of right femur *(Transverse, Oblique, spiral, Comminuted, other) Chapter 21: Factors influencing health status and contact with health services (Z00-Z99) ICD-9 ICD-10CM V54.81 Aftercare following Joint replacement (Add code for joint V43.6_) V s Z47.1 After care following joint replacement (Add code for joint Z96.6 ) Z s 26

28 ICD-9 to ICD-10 What is Different? MI Codes Change in time frame from 8 weeks to 4 weeks MI NOS: ICD-9 = (up to 8 weeks) ICD-10 = I21.3 (up to 4 weeks) Default Coding: Other ICD-10 Tidbits Hemiplegia/monoplegia ( as in CVA LE): Assume right side is dominant when not noted in documentation. Diabetes Type I or type II Assume type II when not stated HTN and CKD: Same guidelines as ICD-9 Anemia associated with malignancy: FOC is Anemia, code CA site first Anemia d/t chemotherapy: FOC is Anemia, code Anemia first, then CA site, then adverse effect code Emphasize the need for: Experts in ICD-9 Fast Learners in ICD-10 Management that can work efficiently supervising both. Executives that budget realistically to accomplish these objectives. 27

29 Industry Coder Demand- 21% With an anticipated increase in demand of over 21%, home health and hospice will compete across the health care spectrum for ICD-10 ready coders. Staffing plans should include: Review of current coders retention strategy Consider longevity/retention bonus Anticipate coder retirements Measure current records per coder demand allow for 30% more staffing to cover transition at a MINIMUM START HERE! VERY IMPORTANT PAGES Next Webinar: Building Our National Cheat sheet Wednesday January 15, :00N EST 28