OASIS Alert

Published on Fri Apr 08, 2005 PDF

Stop losing money because of AD coding errors

You can code Alzheimer's Disease in M0230 as primary - but you can bet your intermediary will take a long, hard look at your documentation when you do.

Intermediaries can't use edits to deny many services to Alzheimer's patients with dementia, but that doesn't mean they don't question your choice when the Alzheimer's case mix diagnosis is in M0230.

Since the Centers for Medicare & Medicaid Services clarified in 2001 that therapy, medication management and psychological services can be medically necessary services for patients with AD, agencies have struggled with when to code AD as the primary diagnosis and how to support that coding choice.

AD is like other conditions treated at home: Show that the patient (or caregiver) is willing and able to learn and that you can reasonably expect the patient to improve. Generally, showing the condition is newly diagnosed or an exacerbation with several aspects of the condition requiring treatment is important, says clinical consultant Judy Adams with Charlotte, NC-based LarsonAllen Health Care Group.

Here's how to decrease your AD denials:

1. Plan and document carefully if AD is primary. Remember, the primary diagnosis is the most acute disease that requires the most services, says coder and consultant Dio Namocatcat with the Visiting Nurse Regional Health Care System in Brooklyn, NY.

Example: The nurse goes in to monitor IV antibiotics used to treat an Alzheimer's patient's pneumonia following his return from the hospital, but then realizes the patient is having swallowing difficulties. She has speech therapy come in to work with the patient and family to try to prevent further aspiration. Would you code pneumonia or Alzheimer's?

Strategy: Dementia includes a constellation of problems including swallowing difficulties, speech-language pathologists confirm. Dementia is a manifestation of AD, and the resulting swallowing difficulties seem to require more intensive services than the ongoing treatment for the pneumonia, so you would code AD as primary, says Namocatcat.

Then, focus on developing a plan of care that addresses the full complement of services you plan to provide. These may include educating the caregiver or family about the stages and progression of the disease process, safety, medication effects or side effects, what to report to the physician, emergency procedures, or ways to promote and maintain function for as long as possible, says consultant Lynda Dilts-Benson with St. Peters-burg, FL-based Reingruber & Co.

Finally each clinician must thoroughly document the care she provides. Often clinicians do not accurately document their services and may focus mostly on one issue, such as incontinence, Adams says. Instead, document the entire scope of care needed and provided, she advises.

2. Code manifestations accurately. Manifestation codes continue to confuse inexperienced home health coders. In conditions where underlying diseases have multiple body system manifestations, official coding guidelines (Section IB) require you to code the underlying condition first, followed by the manifestation.

Coding the above example: For the patient admitted with swallowing difficulties and on antibiotics for pneumonia (see #1 for details), you can provide a lot of information with good coding. Because dementia is a manifestation of AD, Namocatcat suggests the following coding strategy:

M0230(a) 331.0 (Other cerebral degenerations; Alzheimer's disease)

M0240(b) 294.10 (Dementia in conditions classified elsewhere without behavioral disturbance)

M0240(c) V57.3 (Speech therapy)

M0240(d) 787.2 (Dysphagia)

M0240(e) 486 (Pneumonia, organism unspecified)

M0240(f) V58.83 (Encounter for therapeutic drug monitoring)

3. Include codes supporting therapy. Using coding to show why the patient needed a therapist may prevent payment problems up-front, experts say. For example, regional home health intermediary Palmetto GBA still expects a functional diagnosis to support therapy necessity, Adams says. So if you code gait abnormality, dysphagia, speech issues or incontinence, you give a more complete picture of the patient's condition.

Editor's Note: For more diagnosis coding help, order Eli's Home Health ICD-9 Coding Alert at 1-800-874-9180. To see two case examples where Alzheimer's is correctly coded as primary, go to www.palmettogba.com, click on "medical policies" then "draft" then "05HH-001-D."