ICD-10-CM HOT SPOTS - The Carolinas CenterThe …cchospice.org/.../uploads/2015/09/F4-Judy-Adams-ICD-10-CM-Hot-Spots...within the healthcare setting are required to be reported

9/9/2015

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ICD-10-CM HOT SPOTS:PART 1 - CODING MENTAL DISORDERS

39th Annual Hospice & Palliative Care Conference

Columbia, SC

September 30, 2015

Adams Home Care Consulting, Inc.

2016 Final Hospice Rule Coding Issues

• Primary Diagnosis for hospice: The diagnosis most

contributory to the terminal prognosis of the

individual.

• In the instance where two or more diagnoses equally

meet the criteria for principal diagnosis, ICD-20-CM

coding guidelines do not provide sequencing direction,

and thus, any one of the diagnoses may be sequenced

first, meaning to report all of those diagnoses meeting

the criteria as principal diagnosis.

Adams Home Care Consulting, Inc. 2

2016 Final Hospice Rule Coding Issues

• 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.

• ICD-10-CM coding guidelines are clear that all diagnoses

affecting the management and treatment of the individual

within the healthcare setting are required to be reported.


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CMS Comments In 2016 Rule• Although established coding guidelines are required, it

does not appear that all hospices are coding per coding

guidelines on hospice claims.

• Analysis of 2014 claims data indicates that 49% of hospice claims

listed only one diagnosis, yet based on additional analysis, 50% of

those beneficiaries had, on average, eight or more chronic

conditions and 75% had, on average, five or more chronic

conditions.

• In Hospice Wage Index for FY 2013 Notice, CMS stated that

hospice should report all coexisting or additional diagnoses that are

related to terminal illness; and they should not report diagnoses

that are unrelated to terminal illness even though coding guidelines

required the reporting od all diagnoses that affect patient

assessment and planning.


CMS Comments for the Change

• “ There are widely varying interpretations as to what

factors influence the terminal prognosis of the individual

and which conditions are related.”

• “Based on numerous comments received in previous

rulemaking and anecdotal reports from hospices, hospice

beneficiaries and non-hospice providers, we are

concerned that hospices may not be conducting a

comprehensive assessment nor updating the plan of care

as articulated by the CoPs to recognize the conditions

that affect the individual’s terminal prognosis.”


CMS’ Conclusion

• “Therefore, we are clarifying that hospices will report all

diagnoses identified in the initial comprehensive

assessment on hospice claims, whether related or

unrelated to the terminal prognosis of the individual

effective October 1, 2015. This will include reporting of

any mental health disorders and conditions that would

affect the plan of care.”

• Source: Section F, Clarification Regarding Diagnosis

Reporting on Hospice Claims, FY 2016 Hospice Wage

Index and Payment Rate Update and Hospice

• Quality Reporting Requirements


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Updates, Changes and

Clarifications

in ICD-10-CM


Severity - Non-pressure Ulcers• ICD-10-CM introduced the new concept of adding an additional code

from L97.- for all non pressure ulcers to describe the location and laterality with the 4th and 5th character and severity of the ulcer with the 6th character.

• 6th character options are:

• Unspecified

• Limited to skin breakdown

• Fat layer exposed

• Muscle necrosis

• Bone necrosis

• Official guidance states that a clinician other than the provider can determine the severity level that must be documented in the medical record.

• There is no guidance in the official Coding Guidelines to further define how to assign the severity when an ulcer clearly involves muscle or bone, but there is no visualization of necrosis (e.g., necrosis is not evident).


Issues with Non-pressure Ulcer Severity

• General questions

• Bone necrosis cannot typically be seen by visualization alone and requires confirmation by x-ray or CT scan of the bone necrosis.

• There is concern on how to code these when a non-pressure ulcer clearly involves muscle or bone structures without visualization of presence of necrosis.

• Concensus of a panel of expert home health coders:

• At a minimum, code to the degree of tissue involvement definitely known (e,g, into fat layer)

• Do not code unspecified for ulcers that do not meet the specific descriptions.

• Queries for further information to the Coding Clinic have resulted in the following clarifications to date:

• Assigning a 6th character to indicate muscle or bone necrosis must be based on provider documentation and must indicate the presence of necrosis in muscle or bone to use the level 3 and 4 severity.


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Follow Up on Non-Pressure Ulcers

• Continue to submit additional clarifying questions.

• Possibly present a proposal to Coordination and

Maintenance Committee for new codes to provide options

for other levels of severity involving muscle and bone

structures without evidence of necrosis present.


7th Character ‘A’

Hullabaloo


What We Know


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Official Guidelines

Coding and Reporting

In the context of these guidelines, the term

provider is used throughout the guidelines to

mean physician or any qualified health care

practitioner who is legally accountable for

establishing the patient's diagnosis.


Chapter 19 Specific Guidance

• While the patient may be seen by a new or

different provider over the course of

treatment for an injury, assignment of the 7th

character is based on whether the patient is

undergoing active treatment and not whether

the provider is seeing the patient for the first

time.



• 7th character “A”, initial encounter is used while

the patient is receiving active treatment for the

condition

• Examples of active treatment are:

‐ surgical treatment

‐ emergency department encounter evaluation

‐ continuing treatment by the same or a different

physician


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• 7th character “D” subsequent encounter is used for

encounters after the patient has received active

treatment of the condition healing or recovery phase

• Examples of subsequent care are:

‐ cast change or removal

‐ x‐ray to check healing status of fracture,

‐ removal of external or internal fixation device

‐ medication adjustment

‐ other aftercare

‐ follow up visits following treatment of the injury or

condition


Examples of Sequela (Late Effects)

• A 7th character ‘S’ is used when the initial illness/injury has been treated and there is an existing residual effect.

• Examples:

• Patient status post open fracture left femur secondary to an accidental gunshot wound 18 months ago is admitted for intractable pain in the left hip due to traumatic arthritis. Secondary to femur fracture. (M12.552, traumatic arthritis L hip, S72.002S, fracture unspecified part of neck left femur, sequela)

• Patient admitted for chronic respiratory failure after an acute admission for treatment of an accidental overdose, (J96.10, Chronic respiratory failure unspecified whether hypoxia or hypercapnia and T50.901S, Poisoning by unspecified drugs, medicaments and biological substances, accidental sequela.


Official Guideline Revision - 2015

• For complication codes, active treatment refers to

treatment for the condition described by the code, even

though it may be related to an earlier precipitating

problem.

• For example, code T81.4XXA, Infection following a

procedure when active treatment is provided for the

infection.

• Even though the condition relates to a procedure that

occurred at a previous encounter.


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Recommendations

• Do not panic and immediately change to a 7th character of

‘A’ for all codes requiring a 7th character in ICD-10.

• Read the Chapter 19 guidelines carefully and make your

own determination of which 7th character is most

appropriate.

• Many codes related to injuries and fractures are not

complicated and involve subsequent care and should be

coded with a 7th character ‘D’ and not with a 7th character

of ‘A’.

• Watch for further direction from CMS and further

clarification from AHIMA.


Coding Mental Health Disorders



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F01 Vascular Dementia

• Decline in thinking skills caused by conditions that block or

reduce blood flow to the brain, depriving brain cells of vital

oxygen and nutrients.

• F01 is always coded as a secondary code – never first listed

or coded as a primary diagnosis! See “code first” note in

Tabular:

– F01.50 Vascular dementia without behavioral disturbance

– F01.51 Vascular dementia with behavioral disturbance

• Occurs as a result of:

– Infarct(s) of brain due to cerebrovascular disease,

including hypertensive vascular disease.


F01 Vascular Dementia

• Documentation in the record must support code

assignment of vascular dementia.

• May be present with other forms of dementia (i.e.

Alzheimer’s dementia, Lewy body dementia, etc.)

― If more than one form of dementia present, code them all.

• Behavioral disturbances include aggressive, combative,

• and violent behaviors.

• If applicable, also use additional code to identify

wandering in vascular dementia (Z91.83) if patient has

behavioral disturbance


F02 Dementia in other diseases

classified elsewhere• Manifestation code! Cannot be primary!

• Code first the underlying physiological condition. For

example:

– Alzheimer’s disease (G30.‐)

– Dementia with Lewy bodies (G31.83)

– Fronterotemporal dementia (G31.09)

– Parkinson’s disease (G20)

– Creutzfeld‐Jacob disease (A81.0‐)

• “Excludes 1 note: dementia with Parkinsonism (G31.83)”

– probable error in tabular – see code first list which

includes G31.83


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F02 Dementia in other diseases

classified elsewhere• Excludes 2 Note:

– Dementia in alcohol and psychoactive substance

disorders (F10‐F19, with .17, .27, .97)

– Vascular dementia (F01)

• Code F02 with or without behavioral disturbance:

– F02.80 without behavioral disturbance

– F02.81 with behavioral disturbance

• If applicable, use Z91.83 to identify wandering in

dementia in diseases classified elsewhere if patient has

behavioral disturbance.


F03 Unspecified Dementia

• F03.9‐ Unspecified dementia

– Presenile dementia, NOS

– Presenile psychosis, NOS

– Primary degenerative dementia, NOS

– Senile dementia, NOS

– Senile dementia, depressed or paranoid type

– Senile psychosis

• F03.90 Unspecified dementia w/o behavioral disturbance

– Dementia NOS

• F03.91 Unspecified dementia with behavioral disturbance

– Add Z91.83 to identify wandering in unspecified dementia

with behavioral disturbance, if applicable. Wandering is not

integral to dementia.


F05 Delirium Due to Known

Physiological Condition• Code first the underlying physiological condition

• Includes:

– Acute or subacute confusional state (nonalcoholic)

– Acute or subacute infective psychosis

– Delirium superimposed on dementia

– Delirium of mixed etiology

– Sundowning

• Excludes 1: Delirium NOS (R41.0)

• Excludes 2: Delirium tremens alcohol‐related or

• unspecified (F10.231 or F10.921)


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Case Example

• Patient admitted for management of severe neurogenic

dysphagia who has late onset Alzheimer’s dementia with

aggressive behavior and sundowning and also vascular

dementia due to a CVA 2 years ago. Patient is a

wanderer.

Diagnoses ICD-10-CM

M1021

M1023

M1023

M1023

M1023

M1023

M1023


Case Example Answer • Patient admitted for management of severe neurogenic

dysphagia who has late onset Alzheimer’s dementia with

aggressive behavior and sundowning and also vascular

dementia due to a CVA 2 years ago. Patient is a

wanderer.ICD-10-CM

M1021 Neurogenic dysphagia R13.9

M1023 Alzheimer’s Disease with late onset G30.1

M1023 Alzheimer’s dementia w/ behavioral disturbance F02.81

M1023 Delirium superimposed on dementia (sundowning) F05

M1023 Cognitive deficits following cerebral vascular

disease/strokeI69.31

M1023 Vascular dementia w/ behavioral disturbance F01.51

M1023 Wandering in dementia Z91.83


F10‐F19 Mental & Behavioral Disorders

Due to Psychoactive Substance Abuse• F10.‐ Alcohol related disorders

– Use additional code for blood alcohol if applicable (Y90.‐)

• F11.‐ Opioid related disorders

• F12.‐ Cannabis disorders

• F13.‐ Sedative, hypnotic, or anxiolytic related disorders

• F14.‐ Cocaine related disorders

• F15.‐ Other stimulant related disorders

• F16.‐ Hallucinogen abuse

• F17.‐ Nicotine dependence

• F18.‐ Inhalant related disorders

• F19.‐ Other psychoactive substance related abuse

– Polysubstance abuse (indiscriminate drug use)


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Coding Guidelines: Mental & Behavioral

Disorders Due to Psychoactive Substance Abuse

• In Remission

– Selection of “in remission” for categories F10‐F19 requires the

provider’s judgment. Appropriate codes are assigned only on

the basis of provider documentation (as defined in the Official

Guidelines for Coding and Reporting).

• Psychoactive Substance Use

– Codes for psychoactive substance use (F10.9‐, F11.9‐, F12.9‐,

F13.9, F14.9‐, F15.9‐, F16.9‐) should only be assigned based

on provider documentation and when they meet the definition of

a reportable diagnosis.

• The codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder and such relationship is documented by the provider.


Coding Guideline:

Psychoactive Substance Abuse• When provider documentation refers to use, abuse and

dependence of the same substance (e.g., alcohol, opioid, cannabis, etc.) only one code should be assigned to identify the pattern of used based on the following hierarchy:

– If both use and abuse documented – assign only code for

abuse.

– If both abuse and dependence documented – assign only the

code for dependence.

– If use, abuse, and dependence are all documented – assign

only code for dependence.

– If both use and dependence documented – assign only code

for dependence.

• Rule of Thumb: Code the longest word – use, abuse, or

dependence


F20 – F29

• F20 Schizophrenia

– F20.0 Paranoid schizophrenia

– F20.1‐ Disorganized schizophrenia

– F20.2‐ Catatonic schizophrenia

– F20.3‐ Undifferentiated schizophrenia

• Includes atypical schizophrenia

• F21 Schizotypal disorders

• F25 Schizoaffective disorders

• F29 Psychosis, NOS


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F30 – F39 Mood [Affective] Disorders

• F30.‐ Manic episode

– Includes bipolar episode, single manic episode, mixed

affective episode

• F31.‐ Bipolar disorder

– Manic depressive illness, psychosis, or reaction

• F32.‐ Major depressive disorder, single episode

– F32.9 Major depressive disorder, single episode,

unspecified

• Depression NOS (formerly ICD‐9 code: 311)

• F33.‐ Major depressive disorder, recurrent

• F34.‐ Persistent mood [affective] disorders


Case Example

• A 42 year old patient with bipolar disorder, Type II, most recently in a moderate mixed state, was referred to home health by her physician with side effects due to the prescribed lithium carbonate she had been taking. According to her family, she had been not been taking the medication as directed and had been ingesting increasing amounts of alcohol over the last few weeks. She has a long time history of abuse and dependence on alcohol. A drug level for the lithium carbonate was found to be elevated. The patient has been sleeping 18-20 hours per day with severe delirium when she wakes up. She has been diagnosed with a drug-induced hypersomnia as a result of lithium toxicity and alcohol dependence with withdrawal delirium.


Case Example AnswerDiagnosis ICD-10-CM

a Poisoning by other antipsychotics

and neuroleptics, accidental

(unintentional)

T43.591D

b Hypersomnia due to Other

psychoactive substance use

F19.982

c Alcohol use and dependence with

withdrawal delirium

F10.231

d Bipolar disorder, current episode

mixed, moderate

F31.62


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F40 – F49 Anxiety, Dissociative, Stress‐related, Somatoform, and Other Non

Psychotic Mental Disorders

• F41.‐ Other anxiety disorders

– F41.8 Anxiety depression

• Anxiety with depression ‐ not anxiety and depression

– F41.9 Anxiety disorder, unspecified

• F42 Obsessive‐compulsive disorders

• F43.‐ Reaction to severe stress and adjustment disorders

– F43.1‐ PTSD

– F43.2‐ Adjustment disorder (includes culture shock)

• With depressed mood (F43.21)

• With anxiety(F43.22)


Quick Codes

• Recurrent depression, stated as mild

• Anxiety and depression

• Chronic alcohol abuse with dependence

• Delirium superimposed on dementia

• Pseudobulbar affect secondary to multiple sclerosis


Quick Codes • Recurrent depression, stated as mild

– F33.0, Major depressive disorder, recurrent, mild

• Anxiety and depression

– F41.9 Anxiety NOS + F32.9 Depression NOS

• Chronic alcohol abuse with dependence

– F10.20 Alcohol dependence, uncomplicated

• Delirium superimposed on dementia

– F05 Delirium (Code first underlying physiological

condition)

• Pseudobulbar affect secondary to multiple sclerosis

– G35 Multiple sclerosis

– F48.2 Pseudobulbar affect


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Thank you for attending!

Judy Adams, RN, BSN, HCS-D, HCS-O

Adams Home Care Consulting, Inc.

Asheville, NC

828/424-7493

[email protected]

mailto:[email protected]

Documents

ICD-10-CM HOT SPOTS - The Carolinas CenterThe …cchospice.org/.../uploads/2015/09/F4-Judy-Adams-ICD-10-CM-Hot-Spots...within the healthcare setting are required to be reported