Hospice Coding Complexities & Now ICD-10!

CMS has issued instructions related to coding for hospice agencies, reflecting the complexity of care required for terminally-ill patients. One diagnosis alone will not accurately express all of the complications associated with the end of life disease process. The primary diagnosis is the one contributing the most to the terminal condition.

Assigning the additional codes related to the terminal diagnosis can be time-consuming – often taking even more time than coding for a home health patient. Multiple medical conditions must be reviewed and coded if appropriate to describe the patient’s condition. If a diagnosis is considered nonspecific, unspecified or symptomatic, it can no longer be used as a principal diagnosis. “Debility”, “failure to thrive”, and “dementia” are not specific enough to be used as a principal diagnosis, but may be used as a secondary. They are considered as “etiology/manifestations”. When sequencing the codes, the manifestation would follow the code for the underlying condition. 

Additional information is located at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R032CP.pdf.

On October 1, 2015, all healthcare providers are mandated to use ICD-10 codes, after 30 years of ICD-9. ICD-9 has become outdated and contains obsolete terms, and is inconsistent with many current medical practices. ICD-10 allows for greater specificity describing a patient’s diagnosis and assure more accurate billing. ICD-9 has 14,315 codes, while ICD-10 has 69,099 – a nearly 5 times increase! Clinicians and coders will have to have detailed knowledge of physiology and anatomy.


Some of the differences between the two methods:

ICD-9 ICD-10
 3 – 5 characters in length  3 – 7 characters in length
First character is numeric or alpha (E or V) First character is alpha (all letters except U)
Characters 2 – 5 are numeric Character 2 is numeric: characters 3 – 7 are alpha or numeric.
No placeholders  Use of dummy placeholder “X”
 Use of dummy placeholder “X”Alpha characters are case-sensitive Alpha characters are NOT case-sensitive 


As in ICD-9, signs and symptoms will be coded in ICD-10 when: (1) no underlying diagnosis is given by the physician, (2) signs and symptoms most accurately reflect the patient’s condition, and (3) then patient is experiencing signs and symptoms that are not integral parts of a specific disease process. ICD-10 symptom codes provide significantly greater specificity, which will require more-detailed documentation. For example, ICD-9 has one code for abnormality of gait; ICD-10 has six.ICD-10 will be particularly challenging for hospice agencies, because of the need for information from 
the referring physician. Specific information will be gleaned from referrals, history and physicals, and discharge summaries. The days of: “end stage heart disease” are long gone.

Agencies will have to work with referral sources, attending physician, and hospice medical director to define the terminal diagnosis for the patient prior to the start-of-care assessment visit to ensure that the diagnosis is within the coding conventions and not on the “do not use” list.

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