COMPREHENSIVE BILLING SERIES - PART 8 DIAGNOSIS CODING. for clients of: Content developed and presented by:

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1 COMPREHENSIVE BILLING SERIES - PART 8 DIAGNOSIS CODING for clients of: Content developed and presented by: Polaris Group 3030 N. Rocky Point Drive, Suite 240 Tampa, FL

2 COMPREHENSIVE BILLING SERIES-PART 8 Limited Copyright: August 2017, Polaris Group All materials are protected under the copyright laws. The limited copyright allows the purchaser to copy for use but not for distribution FH04h - Developed by Polaris Group Page 1 of 78

3 COMPREHENSIVE BILLING SERIES-PART 8 POST-TEST 1. The care team needs to identify and sequence codes to ensure an accurate claim. a. True b. False 2. The current V codes for Therapy do not exist in ICD-10-CM. Which statement(s) below apply: a. Z51.89 Encounter for otherwise specified aftercare in ICD-10-CM could be used on claim to indicate therapy services b. Underlying diagnosis would be listed first on claim c. Still use treatment diagnoses for therapy on claim d. All of the above 3. For aftercare of a fracture, assign the acute fracture code with the appropriate 7th character such as D for Subsequent (aftercare) or S for Sequela (complications or late effects). c. True d. False 4. Default codes may only be used if here is no other specific information in the clinical record. a. True b. False 5. Which 7 th character code is most often used in the skilled nursing setting? a. E b. J c. M d. D 6. The Business Office should select the diagnosis for the claim. a. True b. False 7. The diagnosis for continued stay should be reflected in which field on the UB04? a. Field 65 b. Field 67 c. Field 70 FH04h - Developed by Polaris Group Page 2 of 78

4 COMPREHENSIVE BILLING SERIES-PART 8 POST TEST ANSWERS 1. The care team needs to identify and sequence codes to ensure an accurate claim. True 2. The current V codes for Therapy do not exist in ICD-10-CM. Which statement(s) below apply: a. Z51.89 Encounter for otherwise specified aftercare in ICD-10-CM could be used on claim to indicate therapy services b. Underlying diagnosis would be listed first on claim c. Still use treatment diagnoses for therapy on claim d. All of the above 3. For aftercare of a fracture, assign the acute fracture code with the appropriate 7th character such as D for Subsequent (aftercare) or S for Sequela (complications or late effects). True 4. Default codes may only be used if here is no other specific information in the clinical record. True 5. Which 7 th character code is most often used in the skilled nursing setting? a. E b. J c. M d. D 6. The Business Office should select the diagnosis for the claim. False 7. The diagnosis for continued stay should be reflected in which field on the UB04? a. Field 65 b. Field 67 c. Field 70 FH04h - Developed by Polaris Group Page 3 of 78

5 COMPREHENSIVE BILLING SERIES 1 Introduction The ICD-10-CM classification system - developed by the National Center for Health Statistics (NCHS). ICD-10-CM stands for International Classification of Disease, 10 th revision, Clinical Modification. Clinical modification - developed by the World Health Organization (WHO) for use in the United States for morbidity and mortality reporting. 2 FH04h - Developed by Polaris Group Page 4 of 78

6 Benefits of ICD-10-CM ICD-10-CM represents a significant improvement over ICD-9-CM: Combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition Addition of sixth and seventh characters 4th & 5th digit sub-classifications Laterality (left, right, bilateral) Greater specificity in code assignment Expanded injury codes including fractures 3 Consequences of Incorrect Coding Increased claim rejections and denials Increased delays in processing authorizations and reimbursement claims Compliance issues Decisions based on inaccurate data Problems can be mitigated with proper training 4 FH04h - Developed by Polaris Group Page 5 of 78

7 Structural Differences Between ICD-9-CM and ICD-10-CM ICD-9-CM 3-5 characters First character is numeric or alpha Characters 2-5 are numeric Always at least 3 characters Use of decimal after 3 characters ICD-10-CM 3-7 characters Character 1 is alpha Character 2 is numeric Characters 3-7 are alpha or numeric Use of decimal after 3 characters Use of dummy placeholder x Alphabetical characters are not case-sensitive 5 Other Differences Between ICD-9-CM and ICD-10-CM ICD-9-CM 14,025 codes Only uses 2 letters E, V 17 Chapters Hospital codes not used in LTC V-Code Multiple therapies as primary ICD-10-CM 68,069 codes Uses all letters except U 21 Chapters Acute codes with appropriate 7 th character to indicate subsequent care or sequela No Z code for Multiple Therapies as primary 6 FH04h - Developed by Polaris Group Page 6 of 78

8 Combination codes for conditions and common symptoms or manifestations Combination codes for poisonings and external causes Added laterality Expanded codes: injury, diabetes, alcohol/substance abuse, postoperative complications Added extensions for episode of care Expanded detail relevant to ambulatory and managed care encounters Inclusion of clinical concepts that did not exist in ICD-9-CM Changes in timeframes specified in certain codes FH04h - Developed by Polaris Group Page 7 of 78

9 FY 2017 Updates 9 New Codes CDC has released around 1900 new ICD-10 codes that went into effect on October 1, There is increased specificity and laterality codes that have been added including Diabetes and Fractures. For example, you can now differentiate which side for Diabetes with diabetic retinopathy E DM d/t underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye 10 FH04h - Developed by Polaris Group Page 8 of 78

10 ICD-10 Flexibilities Expire October 1, 2016 A 12-month grace period meant to ease providers transition to Medicare ICD-10 will officially come to a close on Oct. 1, Centers for Medicare & Medicaid Officials said. In an update to a ICD-10 question and answer sheet, CMS confirmed the flexibilities will expire one year from the official roll-out of the new codes, with no extension or additional flexibility guidance planned. 11 ICD-10 Flexibilities Expire October 1, 2016 Under the flexibilities, providers claims were not denied or audited for unintentional code errors as long as they contained a valid code from the correct family. The update also confirmed that Medicare will not phase in a requirement to code to the highest level of specificity, stating providers should already be coding to that level. 12 FH04h - Developed by Polaris Group Page 9 of 78

11 ICD-10 Flexibilities Expire October 1, 2016 ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud, the update reads. As of October 1, 2016, providers are required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines. 13 Zika Virus New code: A92.5 Zika Virus Code only confirmed cases If the provider documents suspected, possible or probable Zika, do not assign code A92.5. Assign a code(s) explaining the reason for encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. 14 FH04h - Developed by Polaris Group Page 10 of 78

12 Clarification to With Definition The word with should be interpreted to mean associated with or due to when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List Update: The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. 15 Clarification to With Definition These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related. 16 FH04h - Developed by Polaris Group Page 11 of 78

13 Code Assignment and Clinical Criteria 2017 Update: The assignment of a diagnosis code is based on the provider s diagnostic statement that the condition exists. The provider s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. 17 Diabetes Mellitus and the Use of Insulin and Oral Hypoglycemic Drugs 2017 Update: Code Z79.4, Long-term (current) use of insulin, or Z79.84, Long term (current) use of oral hypoglycemic drugs, should also be assigned to indicate that the patient uses insulin or hypoglycemic drugs. 18 FH04h - Developed by Polaris Group Page 12 of 78

14 Hypertension The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term with in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. 19 Hypertension For hypertension and conditions not specifically linked by relational terms such as with, associated with or due to in the classification, provider documentation must link the conditions in order to code them as related. 20 FH04h - Developed by Polaris Group Page 13 of 78

15 Pressure Ulcer Coding For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission. If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: 21 Pressure Ulcer Coding One code for the site and stage of the ulcer on admission AND Second code for the same ulcer site and the highest stage reported during the stay. 22 FH04h - Developed by Polaris Group Page 14 of 78

16 NIHSS Stroke Scale The NIH stroke scale (NIHSS) codes (R ) can be used in conjunction with acute stroke codes (I63) to identify the patient's neurological status and the severity of the stroke. The stroke scale codes should be sequenced after the acute stroke diagnosis code(s). Remember that we do not use Acute Stroke Codes I60-I67 in LTC, but look out for these stroke scale codes from hospital. 23 Coding Conventions and Terms in ICD-10-CM 24 FH04h - Developed by Polaris Group Page 15 of 78

17 Default Codes The default code is listed next to a main term in the ICD-10- CM Alphabetic Index. Family of codes then listed under main term/default code Represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned. So if you just have a generic diagnosis with no detail use code listed next to main term. 25 Default Code Example So if you didn t have any more information than a generic dx of Hypertension, you would use the code next to main term hypertension which is I10 26 FH04h - Developed by Polaris Group Page 16 of 78

18 Default Code Example So if you didn t have any more information than a generic dx of Diabetes, you would use the code next to main term which is E Family of Codes Family of codes refers to codes that have the same letters/numbers for the first three characters before the decimal. We want to use codes from the same family For example, if you are coding E11 for type 2 diabetes, you pick combination codes from this family of codes. You would not want codes from E11 (type 2) on the same diagnosis list/claim with codes from E10 (type 1). 28 FH04h - Developed by Polaris Group Page 17 of 78

19 Family of Codes Example E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E Type 2 diabetes mellitus with foot ulcer **All of these codes could be on same claim since from the same family of codes.**** 29 Family of Codes Example Another example would be choosing same underlying cause of cerebrovascular disease in I69 codes. You would want to stay in same number after. indicating same underlying cause I Dysphasia following nontraumatic subarachnoid hemorrhage I Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage NOT: I Aphasia following other cerebrovascular disease 30 FH04h - Developed by Polaris Group Page 18 of 78

20 Placeholder Character The ICD-10-CM utilizes a placeholder character X. The X is used as a placeholder for future expansion. Where a placeholder exists, the X must be used in order for the code to be valid th Characters Certain ICD-10-CM categories have 7 th character. This is noted at the beginning of the Category/Family of Codes Applicable 7 th character is required for all codes within the category/family. The 7 th character must always remain the 7 th character in the data field. If a code that requires a 7 th character is not six characters, a placeholder X must be used to fill in the empty characters. 32 FH04h - Developed by Polaris Group Page 19 of 78

21 Placeholder Character 7 th Character T Disruption of external operation (surgical) wound, not elsewhere classified, - 7 th character required to indicate subsequent encounter The above family of codes requires a 7 th character. Code is only 5 characters Add X as placeholder to create a valid code T81.31xD 33 7 th Characters Episodes of Care definitions related to 7 th Character Sample Common Definitions: (There are many other options) Initial Encounter (A) - receiving active treatment surgical treatment emergency department encounter evaluation and treatment by the same or a different physician (but still during active treatment) 34 FH04h - Developed by Polaris Group Page 20 of 78

22 Initial Encounter Additional Examples Additional examples provided by AHA: Diagnosis and assessment of acute injury and definitive treatment (e.g., suture repair, fracture reduction) Malunions/Nonunions when patient delayed seeking treatment for fracture Referral to orthopedist for injury evaluation and treatment plan development Antibiotic therapy for postoperative infection Wound vac treatment of wound dehiscence 35 7 th Characters We would most likely NOT use the 7 th character A in LTC but need to recognize this code coming from the hospital and know that we would need to change 7 th character to appropriate subsequent character such as D. ****This applies to certain chapters like Chapter 13 (musculoskeletal) and Chapter 19 (Fractures). 36 FH04h - Developed by Polaris Group Page 21 of 78

23 7 th Characters Subsequent Encounter (D) After active treatment during healing and recovery phase/frequently used in LTC cast change or removal removal of external or internal fixation device medication adjustment X-ray to check healing status of a fracture other aftercare and follow-up visits following treatment of the injury or condition 37 Subsequent Encounter Additional Examples Additional examples provided by AHA: Rehabilitative therapy encounters (e.g., physical therapy, occupational therapy) Suture removal Follow up visits to assess healing status (regardless of whether the follow up is with the same or a different provider) Dressing changes and other aftercare 38 FH04h - Developed by Polaris Group Page 22 of 78

24 Subsequent Encounter Fracture malunions and nonunions are assigned the appropriate 7th character for subsequent encounter for malunion or nonunion (unless the patient delayed seeking fracture treatment) th Character Example So S72.001D for example would be Fracture of Unspecified part of neck of right femur, and 7 th character D means subsequent encounter for closed fracture with routine healing. 40 FH04h - Developed by Polaris Group Page 23 of 78

25 Sequela 7th Character Sequela (Late Effect): Residual effect (condition produced) arising as a direct result of an acute condition. When using 7 th character S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The S is added only to the injury code, not the sequela code. The 7 th character S identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code. 41 Sequela Examples Scar formation after a burn Traumatic arthritis following previous gunshot wound Quadriplegia due to spinal cord injury Skin contractures due to previous burns Auricular chondritis due to previous burns Chronic respiratory failure following drug overdose 42 FH04h - Developed by Polaris Group Page 24 of 78

26 Sequela Coding Example 1 Diagnosis: Right claw hand deformity due to old (healed) upper arm median nerve injury would be coded in following order: M S44.11XS Acquired clawhand, right hand Injury of median nerve at upper arm level, right arm, sequela Sequela is listed first followed by the injury that lead to the sequela with 7 th character S. 43 Sequela Example 2 Patient presents for release of skin contracture due to third degree burns of the right hand that occurred due to a house fire five years ago. Principal Dx: L90.5, Scar conditions and fibrosis of skin Secondary codes: T23.301S, Burn of third degree of right hand, unspecified site, sequela X00.0XXS, Exposure to flames in uncontrolled fire in building or structure, sequela 44 FH04h - Developed by Polaris Group Page 25 of 78

27 Chapter Specific Guidelines Will address additional coding guidelines not already covered in General Guidelines 45 Ch. 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. 46 FH04h - Developed by Polaris Group Page 26 of 78

28 Aftercare Z Codes Aftercare Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. 47 Aftercare Z Codes The aftercare Z code should not be used if treatment is directed at a current, acute disease. Use dx code instead. The aftercare Z codes should not be used for traumatic injuries. The aftercare codes are generally first-listed (principal) diagnosis to explain the specific reason for the encounter. 48 FH04h - Developed by Polaris Group Page 27 of 78

29 Chapter 18 Not Classified Elsewhere Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, not Elsewhere Classified (R00-R99) Signs and symptoms that are routinely associated with a disease should not be assigned as an additional diagnosis. Not Classified Elsewhere are common for therapy codes. For example: R26.2 Difficulty in walking, not elsewhere classified R26.9 Unspecified abnormalities of gait and mobility 49 Chapter 19 Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) Expanded injury codes including anatomic site, laterality, type of injury, severity, and complications Most codes require 7 th character Use acute fx code with appropriate 7 th character for subsequent care such as D. 50 FH04h - Developed by Polaris Group Page 28 of 78

30 Application of 7 th Characters in Chapter 19 including Fractures Most categories in this chapter have three 7th character values (with the exception of fractures): A, initial encounter D, subsequent encounter S, Sequela Late effects but not under active treatment for an acute condition (rarely use) More categories are listed for fractures 51 7 th Character Sequela May be appropriate to use 7 th character S for sequela for a fracture May be long-term resident with long term effect of non-healing fracture, but rarely if ever for Medicare resident receiving rehab since that would be subsequent encounter such as D. 52 FH04h - Developed by Polaris Group Page 29 of 78

31 7 th Character 53 ICD-10-CM Websites 54 FH04h - Developed by Polaris Group Page 30 of 78

32 ICD-10-CM Websites CDC CMS 0/2017-ICD-10-CM-and-GEMs.html ICD-9-CM to ICD-10-CM Crosswalk 55 ICD-10-CM Websites AHIMA ICD-10 General Information CMS lookup tool that allows users to search for codes by ICD-10 description keywords: 56 FH04h - Developed by Polaris Group Page 31 of 78

33 Documentation To Support Coding & Claim 57 Responsibility Business Office Manager IS NOT responsible for selection of diagnoses. Business Office Manager IS responsible for ensuring that the codes included on the claim are compliant and consistent with medical record documentation. 58 FH04h - Developed by Polaris Group Page 32 of 78

34 Medicare Claims Processing Manual Chapter 25, SNF Part A Billing SNFs enter the ICD-CM code for the principal diagnosis in form locator (FL 67) on UB-04. The code must be reported according to Official Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V Codes. The code must be the full ICD-CM diagnosis code, including all five digits (for ICD-9) or all seven digits (for ICD-10) where applicable. 59 Medicare Claims Processing Manual Chapter 25, SNF Part A Billing Other Diagnosis Codes Required The SNF enters the full ICD-CM codes for up to 8 additional conditions in the appropriate form locator (FL 67A-Q). Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-CM guidelines. 60 FH04h - Developed by Polaris Group Page 33 of 78

35 Importance of Accurate Coding Principal/Primary Diagnosis (Field 67 of the UB-04) is being scrutinized very closely by the MACs. National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) that require specific diagnoses trigger claims if correct diagnosis is not included. Claims are data mined using the diagnosis. 61 Benefits of Accurate Coding Provides accurate clinical picture of the resident Assists in minimizing Medical Review by Fiscal Intermediary (FI), Medicare Administrative Contractor (MAC), or Recovery Audit Contractor (RAC) Supports Skilled Services provided Supports Medical Necessity of services Helps to ensure appropriate payment Used for future policy making 62 FH04h - Developed by Polaris Group Page 34 of 78

36 Medical Record Must Support Codes Under Audit, use of an unspecified code is acceptable only if there is no additional documentation in record that supports a more specific code which should have been used. With that said, physicians will need to provide more specificity when known. 63 Medical Record Must Support Codes Accurate documentation is the primary responsibility of the physician and other clinical providers. Work now with physicians to get more specific clinical information not currently recorded in your record; focus on Part A. Work with hospital to receive transfer information and discharge summary in a timely manner for new admission. 64 FH04h - Developed by Polaris Group Page 35 of 78

37 Diagnosis Updates for New Admissions Part A 1) Discharge Summary will likely be the best document to provide and support more specific codes. Try to obtain as quickly as possible When received; review and update diagnoses as appropriate 2) Transfer Form (Review first) 3) Physician/NP visit documentation 65 Diagnosis Updates for LTC Residents Long-Term Resident Going to Physician Appointment Ask for diagnosis updates after visit in order to update diagnoses if indicated Long-Term Resident with ER Visit Review form upon return to see if any changes and updated accordingly Long-Term Resident Seen by MD/NP in Facility Update diagnoses based on physician progress notes 66 FH04h - Developed by Polaris Group Page 36 of 78

38 Common Treatment Codes Used by Physical Therapy M62.81 Muscle weakness, generalized R26.2 Difficulty walking, not elsewhere classified R26.9 Unspecified abnormalities of gait and mobility R29.3 Abnormal posture R29.6 Repeated falls 67 Common Treatment Codes Used by Occupational Therapy M62.81 Muscle weakness, generalized R27.8 Other lack of coordination R29.3 Abnormal posture R53.1 Weakness R29.6 Repeated falls R Cognitive Communication deficit R63.3 Feeding difficulties 68 FH04h - Developed by Polaris Group Page 37 of 78

39 Common Treatment Codes Used by Speech Therapy R47.9 R13.10 Unspecified speech disturbances Dysphagia, unspecified, difficulty swallowing NOS R47.01 Aphasia (excludes aphasia following CVA) R47.02 Dysphagia, (excludes following a CVA) I69.xxx Sequelae of cerebrovascular disease codes 69 Diagnosis Codes and the MDS Diagnosis information captured on the MDS in Section I Disease Diagnoses I0100-I7900 (Diseases) includes check-off of 57 common diagnoses I8000 (Other Current or More Detailed Diagnoses and ICD-10-CM Codes) available for listing diagnoses with ICD-10-CM codes 70 FH04h - Developed by Polaris Group Page 38 of 78

40 Oct. 1, 2016 MDS 71 Oct. 1, 2016 MDS 72 FH04h - Developed by Polaris Group Page 39 of 78

41 Oct. 1, 2016 MDS 73 Diagnosis Codes and the UB-04 For Part A residents: Create a list of ICD-10-CM diagnoses and codes upon admission, readmission and as needed (condition changes, MDS schedule, billing cycle) Medical Records, Accounting, Nursing and Therapy Services review diagnosis codes as applicable Discuss diagnoses in Medicare or other appropriate meetings to assist in determining final diagnosis sequencing TRIPLE CHECK Prior to billing each month 74 FH04h - Developed by Polaris Group Page 40 of 78

42 Selection of Principal and Admitting Diagnosis No change in process 75 Admitting Diagnosis UB-04 Field locator 69 ADMITTING DIAGNOSIS - Principal diagnosis relating to condition established after study to be chiefly responsible for the admission. See Medicare Claims Processing Manual for UB-04 field information 76 FH04h - Developed by Polaris Group Page 41 of 78

43 Principal/Primary Diagnosis UB-04 Field locator 67 - Principal/Primary Frequently matches Admitting Diagnosis Field 69 UB-04 Field locator 67 A-Q (Additional Diagnoses) Used to enter up to seventeen additional conditions co-existing at the time of admission which developed subsequently, and which had an effect upon the treatment given for the length of stay. ***Remember that Medicare only sees 8 diagnoses in the electronic file. 77 Selection of Principal Diagnosis The circumstances of inpatient admission always govern the selection of principal diagnosis (FL 67 on UB-04) The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. 78 FH04h - Developed by Polaris Group Page 42 of 78

44 Selection of Principal Diagnosis Since the application of the UHDDS definitions have been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc). Coding Clinic further states that for residents who continue to stay in LTC facilities, the condition requiring the resident to stay should be sequenced first. 79 Primary and Secondary Diagnosis Team determines primary and secondary diagnosis: When, who, & how communicated? Definition of Principal/Primary Diagnosis in SNF: Condition chiefly responsible for the resident s admission to SNF or continued SNF care. Field 67 on the UB-04 Diagnosis Codes on the UB-04 should: Support services provided during the claim dates of service. Describe the conditions that qualify for payment Support medical necessity 80 FH04h - Developed by Polaris Group Page 43 of 78

45 Continued Treatment of Acute Conditions in the LTC Facility Any acute condition treated at the hospital that continues to require follow-up or ongoing monitoring should be coded with an acute diagnosis code as long as the condition persists and require follow-up. In general, the status of the acute condition would be assessed whenever the MDS is updated - resident status change or at monthly review for billing. 81 Continued Treatment of Acute Conditions in the LTC Facility Codes for the acute medical condition treated and resolved in the hospital are assigned and reported by the hospital (i.e., cholecystitis, abdominal aortic aneurysm) but not coded or reported in the LTC facility. The LTC facility reports Z codes to identify the provision of aftercare. 82 FH04h - Developed by Polaris Group Page 44 of 78

46 Continued Treatment of Acute Conditions in the LTC Facility It is inaccurate to report an acute code for a resolved condition because it directly contradicts the Official Coding Guidelines for Coding and Reporting and is non-compliant with HIPAA regulations. 83 Initial Admission A resident was initially admitted to a LTC facility to receive physical and occupational therapy services due to aftercare for a healing right hip fracture. The resident remains in the facility because of his Parkinson's disease. Upon initial admission, the following codes would be reported in ICD-10-CM: Primary - S72.001D Fracture of unspecified part of neck of right femur, 7 th character D (subsequent encounter for closed fracture with routine healing) G20, Parkinson's disease 84 FH04h - Developed by Polaris Group Page 45 of 78

47 Initial Admission Followed by Continued Stay Code S72.001D is resolved and documented (usually at discontinuation of Medicare Part A stay). For the continued stay, (regardless of payer), code G20, Parkinson's disease, becomes the principal/primary diagnosis (reason for continued stay) (FL 67) 85 Continued Stay Followed by Hospital Stay A year later the resident is transferred to the hospital for treatment of pneumonia and returns to the nursing facility with an order for physical/occupational therapies and antibiotics. Upon returning to the facility, the following codes would be reported: Principal/Primary diagnosis: G20, Parkinson's disease (reason for return to the facility) (FL 67) followed by: J18.9, Pneumonia, unspecified organism Therapies would be documented but remember there is no longer a code for therapies. 86 FH04h - Developed by Polaris Group Page 46 of 78

48 Continued Stay Example Current LTC residents who transfer to the hospital to receive treatment for acute conditions (e.g., pneumonia) and return to the facility for further care of their chronic condition (e.g., COPD) may continue to receive care for the acute condition if unresolved. The principal diagnosis (first-listed) is the reason for the continued stay (e.g., COPD) in the nursing facility (FL 67). 87 Coding For Continued Stay A newly diagnosed condition (FL 67A) will be listed after the principal diagnosis (FL 67) to reflect new conditions that affect the resident. (The principal diagnosis may or may not be the reason for Medicare skilled services.) 88 FH04h - Developed by Polaris Group Page 47 of 78

49 Part B Therapy For a current LTC resident receiving Part B therapy services, the principal diagnosis (FL 67) reported on the UB-04 is the reason for the continued stay in the LTC facility. Followed by the diagnosis or condition that warrants the need for the Part B therapy (FL 67A). For example, Parkinson s may be the principal diagnosis (reason they are in nursing home), followed by difficulty walking and history of falls (the reasons for the therapy). 89 Part B Therapy The medical diagnosis (UB-04 FL 67A) that identifies the reason for the Part B therapy services should be listed AFTER the reason for the continued stay (UB- 04 FL 67 principal dx). The principal dx (FL 67) is usually the same as admitting diagnosis (FL 69) for Part B like it is for Part A. Other ICD-10-CM codes for chronic conditions that affect the resident's progress may also be reported to support therapy services (UB-04 FL 67 B-Q). 90 FH04h - Developed by Polaris Group Page 48 of 78

50 Selection of Principal Diagnosis Admissions/Encounters for Rehabilitation When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed. (BIG CHANGE FROM ICD-9- CM) 91 Admission/Encounter for Rehab Example An admission/encounter for rehabilitation for right-sided dominant hemiplegia following a cerebrovascular infarction, report code I69.351, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, as the first-listed or principal diagnosis (FL 67). 92 FH04h - Developed by Polaris Group Page 49 of 78

51 Admission/Encounter for Rehab Example If being admitted for rehab following an injury, assign the acute injury code with the appropriate 7 th character for subsequent care such as D as the first-listed diagnosis. When a patient is being treated at the hospital for an acute medical condition (aspiration pneumonia) and is admitted to SNF for rehab, code the acute condition (aspiration pneumonia) as the first listed/principal diagnosis followed by any chronic conditions. 93 Selection of Principal Diagnosis If the condition for which the rehabilitation service is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis (FL 67). 94 FH04h - Developed by Polaris Group Page 50 of 78

52 Aftercare as Principal/First-Listed For example, If a patient with severe degenerative osteoarthritis of the hip, underwent hip replacement and the current encounter/admission is for rehabilitation, report code Z47.1, Aftercare following joint replacement surgery, as the firstlisted or principal diagnosis (FL 67). 95 Therapy Primary/Medical Diagnosis According to Medicare Program Integrity Manual, the primary or medical diagnosis is the reason for therapy services. Therapy POT for new Medicare Part A stays require the medical reason to support the therapy services as documented by the physician or qualified practitioner. This medical diagnosis may NOT be the same diagnosis as the reason for continued stay (principal/primary/first-listed) diagnosis. 96 FH04h - Developed by Polaris Group Page 51 of 78

53 Therapy Primary/Medical Diagnosis Continued stay Example A patient with Parkinson s disease returns after a hospitalization for pneumonia to start a new Medicare Part A stay. Pneumonia is identified as the medical diagnosis on the therapy POT to support skilled therapy services along with therapy treatment diagnosis. 97 Therapy Primary/Medical Diagnosis Example However, Parkinson s disease is the reason for the continued stay and continues to be sequenced first on record and UB-04. The reason for the new focus of care and Medicare Part A stay (pneumonia) is sequenced second. 98 FH04h - Developed by Polaris Group Page 52 of 78

54 Reporting Additional Diagnoses Process is the same UB-04 Fields 67A-Q 99 Reporting 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. 100 FH04h - Developed by Polaris Group Page 53 of 78

55 Reporting Additional Diagnoses 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. (FL 67A-Q). Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded. UHDDS definitions apply to inpatients in acute care, short-term, long term care and psychiatric hospital setting. 101 Reporting Additional Diagnoses Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc). 102 FH04h - Developed by Polaris Group Page 54 of 78

56 Reporting Additional Diagnoses Some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. 103 Reporting Additional Diagnoses Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. 104 FH04h - Developed by Polaris Group Page 55 of 78

57 Sequencing 105 Principal/Primary and Secondary Diagnosis Sequence Example Principal/Primary: S72.112D, Displaced fracture of greater trochanter of left femur, 7 th character D for subsequent encounter for closed fracture with routine healing. - Field 67 Additional diagnoses (FL 67A-Q) Rehab diagnosis if applicable I25.10 Artherosclerotic heart disease of native coronary artery without angina pectoris I48.91 Unspecified Atrial Fibrillation Z51.81 Encounter for therapeutic drug monitoring Z79.01 Long-term (current use) of anticoagulants 106 FH04h - Developed by Polaris Group Page 56 of 78

58 Diagnosis Coding S72.112D I25.10 I48.91 Z51.81 Z79.01 S72.112D 107 Communication is Key 108 FH04h - Developed by Polaris Group Page 57 of 78

59 Care Team Communication with Billing Nursing Department should utilize a form that is completed upon every admission listing Principal, Admitting and supporting diagnoses. The form should be completed by the appropriate clinical personnel and provided to the Business Office Manager for inclusion on the UB Diagnosis Sheet 110 FH04h - Developed by Polaris Group Page 58 of 78

60 111 FH04h - Developed by Polaris Group Page 59 of 78

61 ICD-10-CM Coding Guidance for Long-Term Care Facilities Page 1 of 8 ICD-10-CM Coding Guidance for Long-Term Care Facilities Diagnostic coding plays several important roles in every healthcare setting, including long-term care (LTC) nursing facilities. Come October 1, 2015, LTC facilities will assign ICD-10-CM codes to capture a resident s clinical conditions. ICD-10-CM facilitates the collection and organization of healthcare statistics on the incidence of diseases. Diagnostic coding is used to: Collect diagnostic and statistical data about people treated by healthcare providers Support clinical decision making Support reimbursement for services provided Comply with federal standards for reporting diagnostic data Provide data to support clinical research and quality improvement activities HIPAA requires that healthcare providers, including LTC facilities, follow the guidance and direction in the ICD- 10-CM code system and the ICD-10-CM Official Guidelines for Coding and Reporting. LTC facility staff should be knowledgeable of ICD coding guidance to ensure appropriate billing and reimbursement. Knowledge of ICD coding guidance also will help ensure a smooth ICD-10-CM implementation on October 1, LTC facilities must educate staff who work with or assign ICD-10-CM codes. Education should include coding rules and regulations related to proper code assignment, especially for principal diagnosis. This Practice Brief provides education on ICD-10-CM as well as guidance for determining the correct principal diagnosis in LTC facilities utilizing ICD-10-CM. ICD-10-CM Coding and Reporting Guidelines The ICD-10-CM Official Guidelines for Coding and Reporting is the companion document to the official version of ICD-10-CM as published on the National Center for Health Statistics (NCHS) website, publicly available for download. The guidelines are approved by the four organizations that make up the Cooperating Parties for ICD-10- CM: the American Hospital Association (AHA), American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS), and NCHS. The guidelines are included in the official version of ICD-10-CM and also appear in Coding Clinic for ICD-10-CM/PCS, which is published quarterly by AHA. 1 Coding Clinic provides guidance on interpreting and applying the ICD-10-CM guidelines. HIPAA requires adherence to these guidelines when assigning ICD-10-CM diagnosis codes. 2 The Cooperating Parties developed the LTC coding guidance in conjunction with the editorial advisory board for Coding Clinic. The guidance in Coding Clinic assists LTC facilities on how the ICD-10-CM Official Guidelines for Coding and Reporting should be interpreted and applied in the long-term care setting, as it was recognized that LTC services are dynamic, depend on many factors, and cover a longer time frame than acute care stays. The guidance was established in order to standardize data collection and assist coding professionals in LTC facilities. 3 Assigning ICD-10-CM codes in LTC organizations is unique because residents often remain in facilities after their initial episode of illness is resolved. For example, a resident may be admitted to receive rehabilitation services for a healing hip fracture but be unable to return home and continues to reside in the facility for other chronic conditions such as Parkinson s disease, chronic obstructive pulmonary disease (COPD), or chronic kidney disease. ICD-10-CM codes are assigned on admission and concurrently as diagnoses arise throughout a stay, often when the minimum data set (MDS) is updated. Codes can be assigned at different intervals, such as a resident s discharge, FH04h - Developed by Polaris Group Page 60 of /17/2015

62 ICD-10-CM Coding Guidance for Long-Term Care Facilities Page 2 of 8 transfer, or expiration. All diagnoses (i.e., additional diseases or conditions) that affect the resident s care are coded per coding guidelines. Diagnostic listing and sequencing will vary depending on the circumstances of the resident s admission or continued stay in the facility. Principal Diagnosis Definition and Guidance Similar to other providers, LTC facilities have varying rules and regulations that require coded data. At times, there may be a conflict in the requirements and terminology. For example, the term primary diagnosis is often used to indicate the reason for skilled Medicare services, which may not be the same reason for the resident s continued stay. The term primary diagnosis, therefore, may conjure different definitions depending on the individual. In the interest of consistency, the term principal diagnosis in this Practice Brief is used to indicate the principal, primary, and first-listed diagnosis. The sidebar on page 47 has additional information on the definitions. Section II of the ICD-10-CM Official Guidelines for Coding and Reporting defines the principal diagnosis and offers guidance on its selection. The Uniform Hospital Discharge Data Set defines principal diagnosis as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. 4 This definition has been expanded to include all non-outpatient settings including LTC facilities. Coding Clinic further states that for residents who continue to stay in LTC facilities, the condition requiring the resident to stay should be sequenced first. 5 In determining the principal diagnosis, coding conventions in ICD-10-CM, the Tabular List, and the Alphabetic Index take precedence over these official coding guidelines. Current LTC residents who transfer to the hospital to receive treatment for acute conditions (i.e., pneumonia) and return to the facility for further care of their chronic condition (i.e., COPD) may continue to receive care for the acute condition if unresolved. The principal diagnosis (first-listed) is the reason for the continued stay (i.e., COPD) in the nursing facility. A newly diagnosed condition will be listed after the principal diagnosis to reflect new conditions that affect the resident. The principal diagnosis may or may not be the reason for Medicare skilled services. Terms for Principal Diagnosis LTC facilities have varying rules and regulations that require coded data. At times, there may be a conflict in the requirements and terminology. For example, the term primary diagnosis is often used to indicate the reason for skilled Medicare services, which may not be the same reason for the resident s continued stay. Therefore the term primary diagnosis may conjure different definitions, depending on the individual. Below are the definitions of the different terms for principal diagnosis: First-listed diagnosis: The diagnosis that is sequenced first. Terms principal and primary are often used interchangeably to define the diagnosis that is sequenced first. Principal diagnosis: Condition established after study to be chiefly responsible for the patient s admission to the hospital. It is always the first-listed diagnosis on the health record and the UB- 04 claim form. This direction applies to nursing homes as stated in the guidelines. Primary diagnosis: This term is often used to indicate the reason for the continued stay in the LTC facility. It is also used interchangeably with principal diagnosis. Note: The Medicare Program Integrity Manual refers to the term primary diagnosis as the diagnosis that is the reason for therapy services. This diagnosis is currently referred to as the medical diagnosis for the therapy evaluation and plan of care and may or may not be the principal, primary, or first-listed diagnosis. FH04h - Developed by Polaris Group Page 61 of /17/2015

63 ICD-10-CM Coding Guidance for Long-Term Care Facilities Page 3 of 8 Principal Diagnosis in Other Regulations The Medicare Program Integrity Manual refers to the term primary diagnosis as the diagnosis that is the reason for therapy services. This diagnosis is also known as the medical diagnosis. The Therapy Evaluation and Plan of Care document for new Medicare Part A stays require the medical reason to support the therapy services as documented by the physician or qualified practitioner. The diagnosis code representing the medical reason may be identified as primary diagnosis or medical diagnosis on the therapy plan. This medical diagnosis may not be the same diagnosis as the reason for the continued stay (principal, primary, or first-listed diagnosis) in the facility. For example, a patient with Parkinson s disease returns after a hospitalization for pneumonia to start a new Medicare Part A stay. Pneumonia is identified as the medical diagnosis on the therapy evaluation and plan of care to support the skilled therapy services along with the appropriate therapy treatment diagnoses. However, Parkinson s disease is the reason for the continued facility stay and continues to be sequenced first on the record and the UB-04. The reason for the new focus of care and Medicare Part A stay (i.e., pneumonia) is sequenced second. The Resident Assessment Instrument (RAI) User s Manual provides instructions for reporting diagnoses that had an impact upon the development of individualized care plans for residents. Diagnoses are part of the MDS. Section I of the MDS 3.0, titled Active Diagnoses, is intended to code disease related to the resident s functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, or risk of death. 6 The term code in the MDS 3.0 does not hold the same specificity as an ICD-10-CM code. Coding the MDS is the process of assigning values (i.e., numbers, check marks, or dashes) to the MDS items which are more groups of ICD codes than directly relatable to the codes in a detailed breakdown. The MDS contains common active diagnoses sets or groups that are to be checked on the form if present in the resident record. However, a resident may have other conditions important to call out in support of care or services provided to the resident. That said, ICD-10-CM diagnosis codes may be listed on the MDS if the diagnostic groups listed in Section I of the MDS does not allow for identification of a condition/diagnostic group that met the criteria listed above as having an impact upon the resident s functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, risk of death, or if more specificity is provided. It is important to remember the diagnoses on the MDS must meet additional timeframe requirements. Therefore, the documentation supporting the diagnoses must be current. The Medicare Claim Processing Manual instructs LTC staff to follow HIPAA s guidance for adhering to instructions in ICD-10-CM and the official guidelines. Appendix A, available with the online version of this Practice Brief in AHIMA s HIM Body of Knowledge, offers regulatory guidance on reporting diagnoses related to reimbursement. Use of Z Codes in LTC Facilities Assigning V codes in ICD-9-CM has long been an area of confusion and controversy in LTC facilities. Many facilities were told not to assign V codes as the principal diagnosis or even at all. Most often this coding directive was handed down from the corporate office to the billing staff as being a directive issued by their Fiscal Intermediary (FI) or Medicare Administrative Contractor (MAC). Z codes in ICD-10-CM are synonymous with V codes in ICD-9-CM. The ICD-10-CM code set and the official guidelines provide specific instruction and guidance to both the coder and billing staff for appropriate use of Z codes in LTC facilities. In long-term care, one of the most common reasons for initial admission is rehabilitation services (i.e., physical, occupational, and speech-language therapy). In contrast to ICD-9-CM there is no equivalent code in ICD-10-CM for Admission for, Encounter for, or Care involving rehabilitation procedures. According to Coding Clinic, when a patient is admitted to the long term care facility specifically for rehab following an injury, assign the acute injury code with the appropriate 7th character (i.e., D for subsequent encounter) as the first-listed diagnosis. 7 FH04h - Developed by Polaris Group Page 62 of /17/2015