1 / 87

2014 PPE Disclosure Statement

2014 PPE Disclosure Statement.

garry
Download Presentation

2014 PPE Disclosure Statement

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 2014 PPEDisclosure Statement It is the policy of the Oregon Hospice Association to insure balance, independence, objectivity, and scientific rigor in all its educational programs. All faculty participating in any Oregon Hospice Association program is expected to disclose to the program audience any real or apparent affiliation(s) that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker from making a presentation. It is merely intended that any relationships should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. This presenter discloses these relationships: Salix Pharm – speakers bureau and scientific advisory board; Grant Funding – AHRQ, CMMI, NINR, The Duke Endowment: Aspire Health – Senior Medical Advisor

  2. Diagnosis Dilemmas and Medication Issues Janet Bull, MD FAAHPM Four Seasons CMO

  3. Objectives • Describe coding issues with debility, failure to thrive, and dementia • Develop competency by examining case studies • Review elements of ICD-9 CM coding guidelines • Discuss attending of record • Understand Part D requirements

  4. What’s the Buzz? • 2015 Final Rule – Wage Index Report • Issues with Diagnosis • Attending of Record Changes • Related vs Unrelated • Hospice Item Set – Quality Reporting • Changes to Notice of Election • Update on payment reform Federal Registry 8/22/2015 http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18506.pdf

  5. Diagnosis on Hospice Claims • Clarification of existing guidelines • 2014 Wage Index report – “we provided in-depth information regarding longstanding, existing ICD-9 coding guidelines.” • CMS looked at 1st Quarter – 72% hospice claims had one diagnosis

  6. Secondary Diagnosis Wanted! 67% all claims Only report primary diagnosis “The reporting of only one principal diagnosis does not lend to a comprehensive, holistic, and accurate description of the beneficiaries’ end-of-life conditions and may not fully reflect the individualized needs in the individual’s required hospice plan of care.”FY 2013 Data

  7. Secondary Diagnosis • Paper UC-04 claim – allows 17 dx • 83714010 electronic claim – 24 dx • CMSexpectshospices to use secondary dx If you are not using secondary diagnosis, need to start!

  8. Use of Nonspecific Symptom Codes • Cannot use any “ill defined diagnosis” as a principle diagnosis (780-799) • Can no longer use debility and FTT -MACs will soon be instructed to return claims for more definitive diagnosis, RTP by Oct 1, 2014 • ICD-9-CM does not allow use of nonspecific codes as principal diagnosis

  9. Top Ten Principal Hospice Dx 9% Source: FY 2002, 2007, 2012 and 2013 hospice claims data from the Chronic Condition Warehouse (CCW).

  10. Debility & Failure to Thrive Source: FY 2002, 2007, 2012 and 2013 hospice claims data from the Chronic Condition Warehouse (CCW).

  11. Debility and FTT • Lack information regarding clinical condition • Need more definitive diagnosis Final Rule 8/22/14

  12. Medicare Claims with Debility/FTT • 50% had ≥ 7 chronic conditions • 75% had ≥ 4 chronic conditions • Chronic Condition Data Warehouse

  13. Debility/FTT Claims – no secondary dx 2012 chronic conditions warehouse

  14. Dementia – What’s the Issue?

  15. Dementia • Issue relates to inappropriate coding • Alzheimer’s - 331 • Senile – 290.0 • Vascular – 290.4 • Follow ICD 9 codes for diagnosis and sequencing rules. Do not use manifestation codes – “in diseases classified elsewhere”

  16. Manifestation Codes • Manifestations are characteristics, signs or symptoms of an illness. When one disease or condition causes another disease or condition, the one that caused it is the etiology and the resulting second condition is the manifestation. • Manifestation codes cannot be principal diagnosis

  17. Other Dementias Medical Codes • Senile degeneration of the brain – 331.2 • Frontotemporal dementia – 331.19 • Dementia with Lewy Body – 331.82 • Late effects of CVD – 438 Psychiatric Codes • Senile dementia – 290 • Dementia with behaviors – 294.11 • Senile dementia with delusions – 290.20

  18. Case #1 80 yo WM in SNF Hypertension, diabetes,dementia, peripheral Neuropathy, CAD, CHF – NYHA III, hypothyroid 2 pound weight loss over 2 months, dysphagia, oxygen at night, B/B incontinence Hospitalized 3 mo ago with CHF, BNP 1856 Fast 6e, BMI 19.8, PPS 40%, 5/6 ADLs BNP – 427, Cr 1.8, Hgb 11 Meds metoprolol, lisinopril, gabapentin, synthroid acetaminophen, insulin, donepezil, atorvastatin Admit or not?

  19. Is this someone we would have put in under debility or FTT? Do they meet a LCD or Prognostic Indicator?

  20. So you decide to admit… • Dementia • Congestive heart failure • Other? How do you decide? Use best evidence guidelines and clinical judgment

  21. Dementia – Mortality Risk Index ✓ ✓ ✓ ✓ ✓ Total 8.1

  22. Mortality Risk Index Risk of estimate of death in 6 months 0 pts 8.9 % 1-2 10.8 % 3-5 22.2 % 6-8 40.4 % 9-11 57.0 % >12 70.0 % Mitchell, SL, JAMA 2004, vol 291, 2734-2740

  23. Prognosis in Dementia • FAST 7c • 39.5 % mortality in 6 mo (poor selectivity) • 22.2% who died had FAST 7c (poor sensitivity) Excluded a substantial portion of patients who died in 6 months – 77.8%

  24. Other Supporting Dementia Dx • Dysphagia – risk of Aspiration • Weight loss • PPS of 40% • Coexisting CHF • Failure to thrive

  25. Congestive Heart Failure • Supporting documentation • Maximally treated on meds • Oxygen • Hyponatremia • Anemia • Cachexia, FTT • Poor functional status • SOB • Previous hospitalization with high BNP • Coexisting renal disease

  26. Is there a ICD-9 CM code for end stage cardiac disease?

  27. Need to dig a little deeper…. • Possible options include • CHF - 428 • Cardiomyopathy - 425 • Ischemic heart disease - 410-414 • Corpulmonale - 415 • Chronic pulmonary heart disease - 416 • Acute myocarditis – 422 • Valvular disease – 424 • Cardiac dysarrythemia – 427 • All other contributing diagnosis on claim form

  28. Choosing Diagnosis “It is often not a single diagnosis that represents the terminal illness of the patient, but the combined effect of several conditions that makes the patient’s condition terminal.”

  29. Secondary Diagnosis/Meds • CHF or dementia (depending on principal) • What about these? • CAD • Hypertension • Diabetes, • Peripheral Neuropathy • Which meds do you cover? • Metoprolol, lisinopril, gabapentin, synthroid acetaminophen, insulin, donepezil, atorvastatin

  30. Example of certification…. 80 yo white male with primary diagnosis of cerebral atherosclerosis(437)*. Secondary diagnosis include vascular dementia (290.4),CHF(428), CAD (414.01), hypertension (401.9), and peripheral neuropathy (443.9) , and FTT (783.41). Maximally treated with cardiac meds, on oxygen at 2 L/min at night, and c/o dyspnea with minimal exertion. PPS 40%, BMI is 19.8, with 2 pound weight loss in past 2 months. FAST 6e, BNP – 437, Cr 1.8, Hgb 11, Sodium 130. * Codes not needed in certification

  31. Do not include comorbidities that do not contribute to the terminal prognosis in the narrative!

  32. Let’s look at a tougher case.. 94 yo WF with mild dementia, osteoporosis, and hypothyroidism. She has been to the ER for falls x 3, sustained a wrist fracture. PPS 60 to 40%, weight loss of 10 pounds with BMI of 19. Only eating 20%, 3/6 ADLs. Do you admit? If so, diagnosis, principal dx? Secondary dx?

  33. Choose the best diagnosis • Principal Dx – Osteoporosis • Secondary Dx – Wrist fracture, FTT • What about Dementia? Hypothryoidism? This question was posed to one of the MACS who confirmed osteoporosis as principal dx

  34. What if only diagnosis ill-defined? 77 year old patient with dysphagia, decreased oral intake, malnutrition with albumin of 2.1, weight loss 10 pounds in 6 weeks with BMI of 17.6. PPS 60 to 30% in 1 month timeframe. No underlying diagnosesor comorbidities. Doesn’t want to return to ER or hospital. Prognosis determined by physician to be < 6 months.

  35. How to Code? • Malnutrition – 263.9 • Dysphagia – 787.20 • Muscle weakness – 728.87 This example given in the Final Rule. Only use ill defined if NO other principal diagnosis relevant

  36. Example of Certification 77 yo WF with principal diagnosis of protein calorie malnutrition (263.9)* and related diagnosis of and failure to thrive (783.7), weight loss, (783.21) and dysphagia. ( 787.21) No other comorbidities. PPS has declined from 60% to 30%, and now dependent on all ADLs. Refuses further hospitalizations or ER, with goals focused on comfort care. * Codes not needed

  37. Coding Guidelines • Malnutrition • Abnormal weight loss “According to ICD 9 Coding Guidelines, codes that fall under the classification “Symptoms, Signs, and other Ill-defined Conditions”, such as “debility” and “adult failure to thrive”, can only be used as a principal diagnosis when a related definitive diagnosis has not been established or confirmed by the provider.” Answer to question posed in Final Rule

  38. But wait! – haven’t the MACs encouraged use of FTT/Debility? • Palmetto MAC – specific LCD on FTT • Furthermore they state In the event a beneficiary presenting with a nutritional impairment and disability does not meet the medical criteria listed above, but is still thought to be eligible for the Medicare Hospice Benefit, an alternate diagnosis that best describes the clinical circumstances of the individual beneficiary should be selected (e.g. 783.21 "abnormal loss of weight" and 799.4 "Cachexia”) http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx

  39. What about NGS? • Decline in clinical status • PPS <70% 2/6 ADL dependence • NGS - Contractors will not make any changes to the edits until we receive direction from CMS in the form of the Change Release Published: May 30, 2013

  40. Proper Coding • To ensure compliance • Implement edits from Medicare Code Editor (MCE) which detect and report errors • Certain codes plugged in to MCE • Effective 10/1/2014 • Inappropriate codes – RTP (Return to Provider)

  41. Specific Codes NOT to use • 290 – Dementia codes • 293 - Delirium • 310 – Organic brain syndrome

  42. New Patient Admissions • Avoid ill defined primary diagnosis if at all possible • Use LCDs for guidance • Include ALL diagnosis affecting prognosis on claim form and in narrative • Medication profile may be helpful in determining diagnosis • Narratives should reflect WHY you are admitting this patient. If patient does not meet LCDs then explain what is causing the < 6 month prognosis

  43. Existing Debility/FTT Patients • Physician – review plan of care and note affected bodily systems, symptoms, and medications • Change to more appropriate diagnosis based on above with use of multiple secondary diagnosis to support • Write order to change diagnosis and document reason for change • Adjust medications covered

  44. Comprehensive Assessment • Determined by the IDG • Related and unrelated diagnosis incorporated into plan of care • Should be an ongoing process when new diagnosis are added

  45. Manifestation Code - Example 1 • Patient referred for vascular dementia – history of CVAs, hypertension, and peripheral vascular disease. • Principal Diagnosis - Cerebral atherosclerosis - 437.0 or Late Effects of Cerebrovascular Disease - 438 • Secondary Diagnosis – Vascular Dementia – 290.4 Example given by Palmetto

  46. Manifestation Code Mr. G is a 69yo BM on dialysis with ESRD. Renal failure is secondary to longstanding type I diabetes. What do you use as your principal diagnosis? • Diabetes, secondary ESRD • ESRD, secondary diabetes • ESRD, no secondary diagnosis

  47. Cause of Renal Failure? ICD-9 Guidelines • Diabetes – primary 250.40 • ESRD – secondary 585.6 ESRD is a manifestation of diabetes. ICD-9 codes states you need to list the etiology as principal diagnosis and follow the proper sequencing rules

  48. Here’s the Confusion... • According to CMS claims manual, “the principal diagnosis is defined as the condition established after study to be chiefly responsible for the patient’s admission” • But the manual also says to follow ICD -9 coding guidelines. • Hospices generally list ESRD is the cause for the patients limited prognosis and use the LCD to support

  49. What does CMS say? • Use ICD 9 guidelines • Hence in this case you would pay for the insulin/diabetes care and renal medications

  50. What’s the Impact? • Medication and treatment costs likely to rise as more diagnosis are captured as secondary • Required to pay for all primary and secondary diagnosis

More Related