Coding and Coverage for Hospice

It should be simple, right?  Choose from a list of codes that describe why your patient is receiving services and go on about your business…..  Piece of cake, right?

Somehow, that isn’t how it goes these days.

The first challenge is to determine what should be put in the diagnosis list.  The answer is quite simple at first glance.  Code every diagnosis that is related to the terminal condition of the patient.  At second glance, how does a diagnosis make the list?  Medicare says that pretty much any diagnosis in the zip code of the patient makes the list.  Old school providers say that only the terminal diagnosis makes the grade.  The real answer is somewhere in between.  Some questions to ask when determining which diagnoses makes the elite list:

  1. Is the diagnosis the reason the patient is terminal?

  2. Is the diagnosis one of the risk factors or underlying causes of the terminal diagnosis?

  3. Is the diagnosis a direct result of the terminal diagnosis?

  4. What happens if you don’t treat the diagnosis?

  5. Does the diagnosis affect the way that a patient responds to or participates in their plan of care?

Obviously, the terminal diagnosis will be included but on occasion, the terminal diagnosis is not clear.  A patient with end stage Alzheimer’s disease and NY Class IV heart failure doesn’t have a long future but it may be difficult to tell which of the diagnoses is terminal.  Use your judgment and if you are compliant in the rest of the coding process, neither the patient nor the hospice will suffer.

A patient who is terminal due to a stroke caused by long-standing hypertension would have Hypertension in the list.  The same patient may be confined to the bed in the final days of life and some skin breakdown towards the end of life is not unusual.  In these examples, the hypertension is an underlying cause of the stroke and the skin breakdown is a result of the stroke.  Both would be coded.

If pain, confusion or other discomfort is a result of not treating the diagnosis, it should be included.  Extremes in blood sugars may be encountered by a patient with a pre-existing diagnosis of diabetes.  Include it.

We see patients taking Statin medications which are generally used to lower cholesterol to prevent heart attacks in the future.  When the future is limited to a few weeks or so, it may not be important to treat the hypercholesteremia because nothing happens if it isn’t treated.

Patients with dementia are unable to respond to the plan of care as well as their clear headed counterparts.  Even when Alzheimer’s disease or other dementias are not the terminal diagnosis, they should be coded.

In the past, there have been hospice providers who have chosen the primary diagnosis based on the perceived cost of treating the diagnosis.  This has never been the correct approach to hospice care.  The hospice is tasked with covering essentially all care related to the terminal condition of the patient.  That does not mean that curative care should be offered for secondary and contributing diagnoses or even that the treatment prior to hospice admission must be followed.

Consider the following examples:

1.       A patient with a diagnosis of diabetes is admitted for services but her terminal diagnosis is heart failure.  Prior treatment was Lantus insulin.  In the interest of comfort, it may be reasonable to check blood sugars much less frequently and treat with a short acting insulin only when the patient is uncomfortable due to symptoms.  Because appetites and medications can interfere with blood sugar levels, longer acting insulins may not be appropriate.  Tight control of blood sugar is not going to help the patient in the long run.

2.       A patient with Alzheimer’s disease becomes severely agitated when his Namenda is withheld.  In order to provide the patient with the greatest level of comfort, the Namenda would continue.

Should a patient be reluctant to discontinue a medication, the family is free to purchase the medications.  However, it most likely will not be covered under the hospice benefit.   If the family has some of the medication from prior to admission, it can be continued while they are approached gently over time about the need for the medication vs the need to reduce the pill burden and potential for side effects.

Keeping these principles in mind, hospice patients can be accurately depicted in the diagnosis list and a care plan addressing the individual patient needs can be created.  It is not difficult but it will never be a reflexive and automatic process, either.  Until patients standardize dying, there will be no standard care plan.

Needless to say, we highly recommend certified ICD-10 coders to ensure that accurate coding is included on claims, changes in the patient condition are reflected in the coding list and you and your staff have time to spend with patients.

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One thought on “Coding and Coverage for Hospice

  1. Candac Sweet

    Dont’ forget about sequencing conventions: example 1 if a diagnosis is due to the Pt.s diabetes then the diabetes must be sequenced first. There are times when the obvious is not as simple as it seems

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