ASSIGNING THE PRINCIPAL DIAGNOSIS the Principal...increased nursing care. Official Coding ......

ASSIGNING THE PRINCIPAL DIAGNOSIS

Mary Ann P. Leonard, RHIA, RAC-CTAHIMA ICD-10-CM Approved Trainer/AmbassadorHealth Information [email protected]

CONFLICT OF INTEREST

CONTINUING EDUCATION CONTACT HOURS

There is no conflict of interest in the

presentation of this program.

The certificate for the Continuing

Education contact hours will be

provided after completion of the

program evaluation tool.

Official Coding Guidelines

ICD-9-CM Official Guidelines for Coding & Reporting

Developed by: Centers for Medicare & Medicaid

Services (CMS) National Center for Health Statistics

(NCHS)

Approved by the Cooperating Parties

CMS NCHS American Health Information

Management Association (AHIMA) American Hospital Association

(AHA)

Published on Center for Disease Control & Prevention (CDC) web site

Must be followed per HIPAA Transaction &

Code Set (TCS) rule and per Section I

coding instructions in the RAI manual

Developed to assist in coding and reporting

situations where the ICD-9-CM code book

does not provide direction Instructions

published in code book take precedence

over any guidelines


LTC PAYMENT SYSTEM

Skilled Nursing Facility Prospective Payment System (SNF PPS)

Per Diem Payment

Covering All Costs for Services Furnished to Medicare Beneficiaries under Part A

Including Routine, Ancillary and Capital Costs <BBA 1997>

Resource Utilization Groups

A case mix system in which payment is based on the resources expected to be used to care for the resident

How Payment Rates are Determined

Reimbursement is Determined by Resource Utilization Group (RUG) that Results from Coding of the MDS Assessment

MDS Assessment Coding Results from Medical Record Documentation of Resident Care Items

The RUG Level is Transferred to the Claim Form (UB-04)

RUG III Classification

Categories

Rehabilitation plus Extensive Services

Rehabilitation

Extensive Services

Special Care II

Special Care I

Clinically Complex

Impaired Cognition

Behavior

Reduced Physical Function


Each RUG Category Relates

To a Distinct Reimbursement

Group

Rate class Rate

RUX 533.65

RUL 468.66

RUC 453.06

RMA 276.93

RLX 278.75

RLB 256.65

RLA 218.95

SE3 321.04

SE2 272.94

CA2 197.54

CA1 183.99

IB2 175.44

IB1 158.54

IA2 172.83

IA1 152.04

BB2 174.14

BB1 157.23

BA2 168.94


Per Diem Reimbursement

Rate

The Payment Rate Includes all Services Provided to a Resident during a Part A Stay for Medicare

Exception: Services Excluded Under Consolidated Billing

Importance of Accurate Diagnosis Coding

Medicare Billing

Accuracy of MDS and RUG Category

Quality Measures

Diagnosis Code Reporting

Plays a Significant Role in the Completion of both the MDS Form and the UB-04.

Relationship

UB-04

Medical RecordMDS

Organization:Section I – ICD-9-CM

A. Conventions

B. General Coding Guidelines

C. Chapter-specific Guidelines

Applies to all care settings



Organization cont.:Section II - Selection of Principal

Diagnosis Applies to all inpatient care

settings including LTC. Principal diagnosis is defined in

Uniform Hospital Discharge Data Set (UHDDS) as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.


Organization cont.: In LTC where claims are submitted for

extended stays, the principal diagnosis listed may change to the reason for which the resident remains in the facility.

Following transfer to the hospital with an anticipated return to the facility, the principal diagnosis will be:

The “primary” reason that the resident is returning or remaining in the facility.

This may not be the reason for Medicare coverage.

Organization cont.: Section III - Reporting

Additional Diagnoses Applies to all inpatient

care settings including LTC.

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.


Organization cont.:Section IV - Diagnostic Coding

and Reporting Guidelines for Outpatient Services

These guidelines are for use by hospital-based outpatient services and provider –based office visits.

These guidelines are not used in LTC


Section I, General Coding Guidelines –Coding Signs & Symptoms

Use signs & symptoms codes when:

A related, definitive diagnosis has not been established

Symptoms are not routinely associated with a disease process

Do not code signs and symptoms that are part of the disease process


Section I, General Coding Guidelines –Multiple Codes for Single Condition

Some diagnoses require more than one code number to correctly identify the condition

Instructions in the Alphabetical Index or Tabular List identify need for additional codes

Generally, the second code is listed in italics.

Examples:

Alzheimer’s Dementia 331.0 [294.11]UTI due to E. coli 599.0 [041.49]


Section I, General Coding Guidelines -Combination Codes

A single, combination code can identify:

Two diagnoses

A diagnosis with an associated secondary process (manifestation)

A diagnosis with an associated complication

If the code fully identifies the conditions involved, assign only the combination code

Examples:Asthma with COPD 493.2Peptic ulcer with GI bleeding 533.40


Section I, General Coding Guidelines –LATE EFFECT

Residual condition (sequela)

Condition that remains after acute phase of an illness

Sequenced first unless otherwise instructed

Cause of sequela listed second

Do not use code for the acute phase of illness

Example:Dysphasia following CVA 438.12


Section I, General Coding Guidelines

-Reporting Same Diagnosis Code More Than Once

Each unique ICD-9-CM diagnosis code may be reported only once for an encounter.

This applies to bilateral conditions or two different conditions classified to the same ICD-9-CM diagnosis code.


Where To Find Diagnoses

The diagnosis is identified by the treating provider

Consultants may provide additional diagnoses but these must be reviewed/approved by the attending physician

If there is a conflict in diagnoses, the attending provider’s documentation supersedes consultants

If the attending provider is silent regarding the condition documented by another treating provider, it is NOT a conflict

Where To Find Diagnoses

Review clinical record, including but not limited to:

Discharge SummaryMD progress notesConsultationsH & POrders

NOTE: the diagnosis must originate with those authorized to diagnose (physician, physician extender) diagnoses cannot be interpreted or assumed

Coding Process in LTC

Create a listing of diagnoses and codes Select principal diagnosis and list

first

The “first listed diagnoses” is the diagnoses that is chiefly responsible for the admission to, or continued residence in, the nursing facility and should be sequenced first.

List additional diagnoses that reflect services provided or clinical conditions (treated, monitored or carry a risk of death)


Do not list diagnoses that are not pertinent to nursing facility stay

Do not list diagnoses that have been resolved or are historical unless clinically significant to staff

Do not code conditions documented as “suspected”, “rule out”, and/or “probable”

Only established diagnoses are coded in LTC


Subsequent Admissions (Readmits)

Following transfer to the hospital with anticipated return to the facility, the principal diagnosis will be:

The “primary” reason that the resident is returning or remaining in the facility.

This may not be the reason for Medicare Coverage

Coding Clinic, 4th quarter, 1999.


Example:

A nursing home resident is transferred to the hospital for treatment of pneumonia. She returns to the nursing home and is still receiving antibiotics for the pneumonia. However, the main reason she is returning to the nursing home is because this has been her residence since developing a CVA with residuals several years ago.

Which diagnosis should be listed first at the nursing home, the pneumonia or sequela of CVA?

LATE EFFECT of CVA

Code Sequencing Definitions in LTC

Secondary diagnoses for LTC:

Any and all conditions that co-exist when resident is admitted to the facility, or

Develop subsequently during a resident’s stay, or

Affect treatment the resident receives or the resident’s length of stay

Diagnoses that relate to an earlier episode which have no bearing on the current stay are to be excluded.


Review diagnosis list with clinical staff as applicable:

Nursing representative (MDS or other)

Therapy

Inclusion of therapy treatment and medical diagnoses

May want to label treatment diagnoses/ codes from therapy


Best practices for when to assign codes (or at least review them):

Long-term care residentsUpon admission &

readmissionWhen new diagnoses

ariseQuarterly (with MDS

schedule)


High acuity residents (i.e. Medicare, skilled or managed care)

Review codes monthly

Codes on MDS, billing claim forms (i.e.

UB04/837), and in medical record

need to support:

Medical necessity

Skilled services provided (may

include therapy treatment diagnosis)

Resource Utilization Group (RUG)

selection as applicable


Triggers for concurrent coding: Change, addition or

discontinuations of therapy services

Recent hospitalization

New diagnoses documented by the medical staff

Significant changes in condition

Resolved diagnoses

Changes in medication – new or discontinued

Use of Diagnoses on the RAI/MDS

Use of Diagnoses on the MDS

Diagnosis information captured on the Minimum Data Set (MDS) in Section I - Disease Diagnoses

Diseases: check-off list of common diagnoses

Infections: check-off list of common infections

Other Current or More Detailed Diagnoses and ICD-9 Codes – text area for listing diagnoses with ICD-9-CM codes


Instructions for completing MDS Section I are found in Chapter 3, Long Term Care Resident Assessment Instrument User’s Manual, Version 3.0

Manual available for download from:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/NursingHomeQualityInits/MDS30RAIManual.html



Review clinical record for current, physician-documented diagnoses

Transfer documentation, including hospital progress notes and discharge summary

Physician medication and treatment orders

Follow Official Guidelines for Coding and Reporting

CURRENT within the look back period

Documented within the past 60 days

Active within the last 7 days

Have a CURRENT relationship to:

Activities of Daily Living (ADL) status

Cognitive status

Mood and Behavior status

Medical Treatments

Nursing Monitoring - includes clinical monitoring by a licensed nurse (e.g., serial blood pressure evaluations, medication management, etc.)

Risk of Death


Do NOT list

Conditions that have RESOLVED or

INACTIVE diagnoses that no longer affect the resident’s function or care plan

Examples:

Resolved pneumonia

History of appendectomy


When diagnosis is more specific than item description in Section I:

Check the more general diagnosis in Section I and

Enter more detailed diagnosis, with ICD-9-CM code, in I8000 if space available

Example:Gouty Arthritis:

I3700 - Check item I1l, arthritis

I8000 - Enter “Gouty Arthritis


Process for Question I2 - Infections Using a 30-day look back for UTIs,

and a 7-day look back period for all other items

Check all infections that apply in I2300

Watch for very specific criteria for UTIs

Code more specific diagnoses in I8000 if space available


DO NOT report procedure codes in Section I

Procedure codes not used in LTC

Results in “fatal error” (record rejection) when submitting an MDS

DO NOT report code on Section I if already captured in other sections of the MDS (Therapies, g-tube, etc.) – do code them as they would appear on the UB-04 form


Section I and RUGs Classification Diagnoses reported in Section I can affect

classification in Resource Utilization Groups (RUGs) used to determine Medicare and/or Medicaid payment rates

I2000 – Pneumonia

I2100- Septicemia

I2900 – Diabetes mellitus

I4400 - Cerebral palsy

I4900– Hemiplegia/hemiparesis

I5200- Multiple sclerosis

I5300 – Parkinson's Disease

I5100– Quadriplegia

I6200 – Asthma & COPD

I6300 – Respiratory Failure



Section I and MDS Assessments Completed for Medicare PPS

Diagnoses and conditions entered on the Medicare PPS assessments should be reflective of ICD-9-CM codes on the UB04/837 for the same time period

Medicare PPS Assessments:

5-day

30-day

90-day

14-day

60-day

OMRA

Medicare Readmission/Return

Section I and quarterly MDS Assessments Each state determines which of the

MDS assessment forms are required for the quarterly assessment

MDS Full Assessment Form

Medicare PPS Assessment Form (MPAF)

MDS Quarterly Assessment Form

MDS Quarterly Assessment Form (Optional Version for RUG IV)

MDS Quarterly Assessment Form (Optional Version for RUG IV)


Section I and the Quarterly MDS Assessment

Report diagnoses based on instructions printed at Section I

Some quarterly MDS forms have the following instruction for Section I "Include only those diseases documented in the last 60 days and active in the last 7 days that have a relationship to current ADL status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death".



Section I and Quality Measures Diagnoses in Section I affect

inclusion, exclusion, and risk adjustment of residents in Quality Measures

I6000 – Schizophrenia

I5350 – Tourette’s Syndrome

I5250 – Huntingdon’s Disease

I2300 – UTI within the last 30 days

Diagnosis Codes on the UB-04 /837

Support reimbursement of claims

Serve as a means of communication between the provider & payer

Describe the conditions that qualify for reimbursement

Support medical necessity


MYTH

The 1500 claim form (aka- HCFA 1500 or CMS 1500 form) is developed by the federal government

FACT

The 1500 form is developed and maintained by the National Universal Claim Committee (NUCC)

The form is in the public domain

The form is used by federal payer programs, e.g. Medicare, Tricare, Black Lung, etc.


The NUCC was formed in 1995 taking over for the Uniform Claim Form Task Force that initially developed the standard professional claim form

NUCC assumed responsibility for the development and maintenance of the 1500 claim form

Its members represent a broad base of payers, providers, standards developers, data content committees, public health organizations and vendors

The AMA is the Secretariat of the NUCC

The website is www.nucc.org


Some of the changes to the form:

Added 8 more diagnoses

Added ICD indicators and two dotted lines for 1-byte indicator

Can use either ICD-9-CM or ICD-10-CM (not both) on the form

Changed labels of the diagnosis code lines to alpha characters (A-L)

Removed the period within the diagnosis code lines


CMS -1500 Claim FormRecently revised (version2/12)

Replaces version 8/05

New form accepted 1/6/14

Medicare will accept only the new form 4/1/14

Allows providers to indicate whether using ICD-9 or ICD-10 codes

Additional diagnoses\is codes from 4 to 12


List diagnosis codes that support services provided during claim dates of service

Items/services billed on the UB-04/837 should be supported by a diagnosis code

Follow Official Guidelines for Coding and Reporting and instructions within the code book to sequence and report diagnoses codes as necessary.


Diagnosis Codes on the UB-04/837: CMS Transmittal 437

Chapter 6, Section 30 of the Medicare Claims processing manual includes the following:

Principal Diagnosis Code- Code must be reported according to Official ICD-9-CM Guidelines

Other Diagnosis Codes Required-Enter 8 additional diagnoses - CMS does not have additional requirements regarding reporting or sequencing of codes other than those in the guidelines

Diagnosis Codes on the UB-04/837

Recommendations: Create a list of diagnoses and codes

upon admit, readmit and as needed (condition change, MDS schedule, billing cycle)

HIM review diagnoses list with nursing and therapy as applicable

Discuss diagnoses in Medicare or other appropriate meeting, finalize diagnosis sequencing


Recommendations:Communicate diagnoses

selected/sequenced to:

Business office – for inclusion on billing claim form (i.e. UB-04/837)

Medical record – for continuity of care

Others as appropriate for your facility


Sample Coding Sequencing & Communication Form

Accurately Reporting ICD-9-CM Codes

Accurate reporting of ICD-9-CM codes affects:

Accurate claim submission (e.g. Medicare)

Quality Measures

Data collected for long term care residents

Overall accuracy of your MDS/RUG categories

Accurately Reporting ICD-9-CM Codes

Report correct & complete diagnosis code numbers

Report correct number of digits Assign 4th, 5th, 6th or 7th digits as

required

NEVER add zeros or nines as “fillers” to an ICD-9-CM code

Changes the meaning of diagnosis

NEVER use a code because it ‘goes through the system’

Accurately Reporting ICD-9-CM Codes: MDS vs Billing Claim Forms

Not all diagnoses reported on MDS are appropriate for billing claim forms (i.e. UB-04/837)

Some diagnosis codes on MDS do not relate to reasons for claim coverage

Keep in mind time frame of MDS vs. billing claim form

Accurately Reporting ICD-9-CM Codes: Billing Claim Forms

Inaccurate and/or incomplete codes can prompt a suspension or rejection of a claim

Inaccurate codes can cause denials or medical reviews

Each FI determines diagnoses to be targeted

Remember the RACs, etc. also use codes to determine audits

Accurately Reporting ICD-9-CM Codes: Billing Claim Forms

Examples of diagnoses targeted for medical review in the past:

Bowel Obstruction

Dementia

Best defense is accuracy in the ICD-9-CM code assignment

ICD-9-CM in Long Term Care is Dynamic

Diagnosis Codes in the Long Term Care Facility are Dynamic. Diagnosis codes

listed depended upon the point in time of the resident’s stay when the coding is done.

Many Facilities Fail to Update the Resident’s List of “Active” Diagnoses

What Diagnosis Codes to List?

Create a List of Diagnoses and codes when appropriate

Upon:

Admission

Readmission

Change in Patient Status

MDS Schedule

Billing Cycle

Report Correct and Complete Codes

Code to the Highest Level of Specificity

Do Not Add Filler Numbers

Report Appropriate ICD-9-CM codes on the UB-04

Not All Diagnoses on the MDS Form are Appropriate to the UB-04.

Listed Diagnoses Codes

List Codes that Support Services Provided during the Dates of Service Reported

Items/Services Billed Should be Related to a Diagnosis Code

Finding the Diagnoses

The Clinical Record is Reviewed for Current Physician (Physician Extender)-Documented Diagnoses.

Transfer Documentation

Physician Medication and Treatment Orders

Current Diagnosis

The Disease or Condition is CURRENT within the Look Back Period

Diagnoses must be documented within the previous 60 days (based on the ARD)

Diagnoses must be ACTIVE within the past 7 days (based on the ARD)

Current Diagnosis

A Current Relationship Must Exist the Diagnoses/Conditions and:

Activities of Daily Living

Cognitive Status

Mood and Behavior Status

Medical Treatments between

Nurse Monitoring

Risk of Death

Disease Conditions

Do Not Report:Conditions That Have Been Resolved

Inactive Conditions:

Those that No Longer Affect:

the Resident’s Functioning

The Resident’s Care Plan

Importance of Communication

Communicate Final Diagnosis Listing/Sequencing with the Business Office, Medical Records and Others as Appropriate

V57.89

438.20V54.89

Diagnosis Coding and the UB-04

Importance: Support Reimbursement

Communication Between Payer and Provider

Describe Conditions and Disease

Support Medical Necessity

ICD-9-CM Reporting GuidelinesCMS Transmittal 437

First Listed Diagnosis Code –Reported According to the Official ICD-9-CM Guidelines

CMS Does Not have Additional Requirements for Reporting or Sequencing other Diagnosis Codes

ICD-9-CM CodesMDS and the Claim

A Correlation Should ExistHowever, Not all Diagnoses Entered on the MDS are Reported on the UB-04

Is the Condition Related to Medicare Coverage?

Acute Care Codes and LTC

Acute Care Codes are Not to be Used in the Long Term Care Setting Unless the Condition or Disease Manifests or is Treated while the Resident is in the Facility

Common Errors Pulling Acute Fracture or

Dehydration Diagnoses from Transfer Documentation

Reporting Fracture Codes

Only Report Fracture Codes (800.XX-829.X) if the Fracture Occurs in Your Facility!

The Fracture Must be Stabilized and Treated in Your Facility

If a Resident is Admitted for Rehab following the Fracture an Aftercare Code is Reported

Determine whether the Fracture is Traumatic or Pathologic to Assign the Correct Code

Consult Physician Documentation to Make the Determination

V-Codes and Long Term Care

Supplementary Classification of Factors Influencing Health Status and Contact with Health Services

Guidance for the Use of V-Codes Section I General Coding

Guidelines

AHA Coding Clinic, 4th Quarter 1999, 4th Quarter 2003

Coding Guidelines for Long Term Care

Medicare Claims Processing Manual, Transmittal 437

Using V Code in Long Term Care

Reason for the Resident’s Stay

Rehab Services (V57)

Orthopedic Aftercare (V54)

Surgical Aftercare (V58)

Assign the Appropriate V-Code as the First Listed Diagnosis

V Codes In Long Term Care

Other V Codes can be used as a “First Listed” Diagnosis

The Following are Generally Used as Secondary Diagnoses in LTC

Attention and Management of Artificial Openings (V55)

Acquired Absence of Organ (V45.7X)

Monitoring Therapeutic Drug Uses (V58.83)


In Extremely Rare Circumstances the Following Could be used as a “First-Listed” Diagnoses:

“Status Post” or “History” V Codes

Must Impact the Resident’s Care

Family History (V16-V19)

Personal History Codes (V10-V13)


Only to be Listed as Secondary Diagnosis:

Amputation Status (V49.6X or V49.7X)

Drug Resistance Present (V09)

Hospice (V66.7)

Long Term (Current) Drug Use (V58.6X)

Organ Replacement Status (V42 or V43)

Personal History Codes (V14-V15)

V Codes and the Alphabetic Index

Look for Key Words

Absence

Aftercare

History of

Resistance

When Coding Scenarios

Determine a List of Diagnosis Codes

Utilize Transfer Documentation

Physician Treatment and Medication Orders

Coding Scenarios

What’s the correct principal or primary diagnosis?

Patient admitted from hospital following an elective total Right hip replacement for DJD. During the hospital stay the patient was transfused with 2 units of blood for acute blood loss anemia and continued to be anemic on iron supplements. Following surgery, the patient was placed on Coumadin until such time the patient was ambulatory for DVT prophylaxis. Patient was sent with orders for PT and OT, check PT/INR 2 x week, and CBC in 2 weeks.

Aftercare following joint replacement

Coding Scenarios


Patient admitted to hospital with slurred speech, facial droop, cognitive loss and dysphagia which was diagnosed as a result of an acute embolic CVA. Patient has ongoing diagnosis of HTN and hyperlipidemia. Prior to discharge from hospital a PEG tube was placed as speech therapy identified oropharyngeal dysphagia. It was noted that rather than placing the patient on Coumadin the patient was placed on Plavix due to history of falls with multiple fractures in the recent past. Patient will be treated with PT, OT, SLP and swallowing therapy at the nursing home.

Late effect CVA, cognitive loss

Coding Scenarios


Resident with PVD secondary to Type I diabetes mellitus with diabetic ulcers of right ankle and calf. Focus of care is on the ulcers.

Diabetes Mellitus Type I with

vascular

Coding Scenarios


Patient was hospitalized for a below-the-knee amputation of the left leg. Following surgery, he developed an infection of the amputation stump which was treated during the hospitalization and the antibiotics were complete at the time of discharge. The patient is now admitted to the nursing facility for dressing changes.

Orthopedic aftercare, following

amputation

Coding Scenarios


Resident admitted to SNF following right lobectomy and excision of sentinel lymph node with metastasis to lymph node. Resident will return in 2 weeks to surgeon for tumor clinic findings to start chemo and radiation therapy.

Aftercare following neoplasm

surgery

RESOURCES

Coding Guidelines; http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm#guidelines

http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm#guidelines

MDS 3.0 Manual; http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30-ArchivedRAIManuals.html

RESOURCES

Medicare Policy Manuals

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS050111.html?DLPage=1&DLSort=0&DLSortDir=ascending




ASSIGNING THE PRINCIPAL DIAGNOSIS the Principal...increased nursing care. Official Coding ......

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