ICD-9-CM Expert for Home Health Services, Nursing Facilities, and Hospices Volumes 1, 2 & 3
International Classification of Diseases 9th Revision Clinical Modification Sixth Edition
Edited by: Anita C. Hart, RHIA, CCS, CCS-P Catherine A. Hopkins Beth Ford, RHIT, CCS
Ingenix is committed to providing you with the ICD-9-CM code update information you need to code accurately and to be in compliance with HIPAA regulations. In the case of adoption of additional ICD-9-CM code changes effective April 1, 2006, Ingenix will provide these code changes to you at no additional cost! Just check back at http://www.IngenixOnline.com and look for the ICD-9-CM Update icon to review the latest information concerning any new code changes. Codes Valid October 1, 2005, through September 30, 2006 Tabular List RESPIRATORY SYSTEM 484–491.20
' 484 Pneumonia in infectious diseases classified elsewhere Bronchioli and Alveoli E X C L U D E S influenza with pneumonia, any form (487.0) 484.1 Pneumonia<<¥ in cytomegalic inclusion disease Code first underlying disease (078.5) 484.3 Pneumonia<¥ in whooping cough Code first underlying disease (033.0-033.9) 484.5 ¥ 484.7 ' Additional Digit Required RUG III Special Care Dx RUG III Clinically Complex Dx Hospice Non-cancer Dx CD PDx Clinical Dimension PDx CD SDx Clinical Dimension SDx k 2006 ICD•9•CM October 2005 • Volume 1 — 133 Tabular List DIAGNOSTIC AND THERAPEUTIC PROCEDURES 92.24–93.37 92.24 T¥> eleradiotherapy using photons 93.08 <¥>Electromyography Megavoltage NOS E X C L U D E S eye EMG (95.25) Supervoltage NOS that with polysomnogram Use of: (89.17) Betatron urethral sphincter EMG (89.23) linear accelerator AHA: J-F, ‘87, 16 92.25 ¥>Teleradiotherapy using electrons DEF: Graphic recording of electrical activity of muscle. Beta particles 93.09 ¥> ' Additional Digit Required RUG III Special Care Procedure RUG III Clinically Complex Procedure RUG III Extensive Services Procedure RUG III Rehab Procedure k 2006 ICD•9•CM October 2005 • Volume 3 — 199 Coding Guidelines Coding Guidelines ICD-9-CM OFFICIAL GUIDELINES FOR CODING 8. “With” 9. “See” and “see also” AND REPORTING B. General coding guidelines Effective April 1, 2005 1. Use of both Alphabetic Index and Tabular List Narrative changes appear in bold text The guidelines have been updated to include the V Code Table. 2. Locate each term in the Alphabetic Index 3. Level of detail in coding The Centers for Medicare and Medicaid Services (CMS) and the National 4. Code or codes from 001.0 through V85.4 Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the 5. Selection of codes 001.0 through 999.9 following guidelines for coding and reporting using the International 6. Signs and symptoms Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). 7. Conditions that are an integral part of a disease process These guidelines should be used as a companion document to the official 8. Conditions that are not an integral part of a disease process version of the ICD-9-CM as published on CD-ROM by the U.S. Government 9. Multiple coding for a single condition Printing Office (GPO). 10. Acute and chronic conditions These guidelines have been approved by the four organizations that make up 11. Combination code the Cooperating Parties for the ICD-9-CM: the American Hospital Association 12. Late effects (AHA), the American Health Information Management Association (AHIMA), 13. Impending or threatened condition CMS, and NCHS. These guidelines are included in the official government version of the ICD-9-CM and also appear in Coding Clinic for ICD-9-CM, C. Chapter-specific coding guidelines published by the AHA. 1. Chapter 1: Infectious and Parasitic Diseases (001–139) a. Human immunodeficiency virus (HIV) infections These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the b. Septicemia, systemic inflammatory response syndrome ICD-9-CM itself. These guidelines are based on the coding and sequencing (SIRS), sepsis, severe sepsis, and septic shock instructions in Volumes 1, 2, and 3 of ICD-9-CM, but provide additional 2. Chapter 2: Neoplasms (140–239) instruction. Adherence to these guidelines when assigning ICD-9-CM a. Treatment directed at the malignancy diagnosis and procedure codes is required under the Health Insurance b. Treatment of secondary site Portability and Accountability Act (HIPAA). The diagnosis codes c. Coding and sequencing of complications (Volumes 1-2) have been adopted under HIPAA for all health care d. Primary malignancy previously excised settings. Volume 3 procedure codes have been adopted for inpatient procedures reported by hospitals. A joint effort between the health care e. Admissions/encounters involving chemotherapy and provider and the coder is essential to achieve complete and accurate radiation therapy documentation, code assignment, and reporting of diagnoses and procedures. f. Admission/encounter to determine extent of malignancy These guidelines have been developed to assist both the health care provider g. Symptoms, signs, and ill-defined conditions listed in and the coder in identifying those diagnoses and procedures that are to be chapter 16 reported. The importance of consistent, complete documentation in the h. Encounter for prophylactic organ removal medical record cannot be overemphasized. Without such documentation 3. Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and accurate coding cannot be achieved. The entire record should be reviewed Immunity Disorders (240–279) to determine the specific reason for the encounter and the conditions treated. a. Diabetes mellitus 4. Chapter 4: Diseases of Blood and Blood-Forming Organs (280–289) The term “encounter” is used for all settings, including hospital Reserved for future guideline expansion admissions. In the context of these guidelines, the term “provider” is used throughout the guidelines to mean physician or any qualified 5. Chapter 5: Mental Disorders (290–319) health care practitioner who is legally accountable for establishing the Reserved for future guideline expansion patient’s diagnosis. Only this set of guidelines, approved by the 6. Chapter 6: Diseases of Nervous System and Sense Organs (320–389) cooperating parties, is official. Reserved for future guideline expansion The guidelines are organized into sections. Section I includes the 7. Chapter 7: Diseases of Circulatory System (390–459) structure and conventions of the classification and general guidelines a. Hypertension that apply to the entire classification, and chapter-specific guidelines b. Cerebral infarction/stroke/cerebrovascular accident (CVA) that correspond to the chapters as they are arranged in the c. Postoperative cerebrovascular accident classification. Section II includes guidelines for selection of principal d. Late effects of cerebrovascular disease diagnosis for non-outpatient settings. Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is 8. Chapter 8: Diseases of Respiratory System (460–519) for outpatient coding and reporting. a. Chronic obstructive pulmonary disease [COPD] and asthma b. Chronic obstructive pulmonary disease [COPD] and bronchitis Section I. Conventions, general coding guidelines and 9. Chapter 9: Diseases of Digestive System (520–579) chapter-specific guidelines Reserved for future guideline expansion A. Conventions for the ICD-9-CM 10. Chapter 10: Diseases of Genitourinary System (580–629) 1. Format Reserved for future guideline expansion 2. Abbreviations 11. Chapter 11: Complications of Pregnancy, Childbirth, and the a. Index abbreviations Puerperium (630–677) b. Tabular abbreviations a. General rules for obstetric cases 3. Punctuation b. Selection of OB principal or first-listed diagnosis 4. Includes and excludes notes and inclusion terms c. Fetal conditions affecting the management of the mother 5. Other and Unspecified codes d. HIV infection in pregnancy, childbirth and the puerperium a. “Other” codes e. Current conditions complicating pregnancy b. “Unspecified” codes f. Diabetes mellitus in pregnancy 6. Etiology/manifestation convention (“code first,” “use additional g. Gestational diabetes code,” and “in diseases classified elsewhere” notes) h. Normal delivery, code 650 7. “And” 2006 ICD•9•CM Revised text in bold font October 2005 • Coding Guidelines—1 Overview of the Home Health Agency Prospective Payment System Section 4603 of the Balanced Budget Act of 1997, as amended by section pre-reclassified hospital wage index. The hospital wage index is adjusted to 5101 of the Omnibus Consolidated and Emergency Supplemental account for the geographic reclassification of hospitals in accordance with Appropriations Act for Fiscal Year 1999 requires the implementation of a §§1886(d)(8)(B) and 1886(d)(10) of the Social Security Act (the Act.) prospective payment system for home health agencies, consolidated billing According to the law, geographic reclassification only applies to hospitals. requirements, and a number of other related changes. The prospective Additionally, the hospital wage index has specific floors that are required by payment system described in this rule replaced the retrospective reasonable- law. Because these reclassifications and floors do not apply to HHAs, the cost-based system used by Medicare for the payment of home health services home health rates are adjusted by the pre-floor and pre-reclassified hospital under Part A and Part B. wage index. NOTE: The pre-floor and pre-reclassified hospital wage index varies slightly from the numbers published in the Medicare inpatient hospital I. Home Health Agency Prospective PPS regulation that reflects the floor and reclassification adjustments. The wage indices published in the home health final rule and subsequent annual Payment System (HHA PPS) updates reflect the most recent available pre-floor and pre-reclassified The unit of payment under home health PPS is a national 60-day episode hospital wage index available at the time of publication. rate with applicable adjustments. The episodes, rate, and adjustments to the rates are detailed in the following sections. 10.3 – Continuous 60-Day Episode Recertification Home health PPS permits continuous episode recertifications for patients who 10.1 – National 60-Day Episode Rate continue to be eligible for the home health benefit. Medicare does not limit A – Services Included: The law requires the 60-day episode to include all the number of continuous episode recertifications for beneficiaries who covered home health services, including medical supplies, paid on a continue to be eligible for the home health benefit. reasonable cost basis. That means the 60-day episode rate includes costs for the six home health disciplines and the costs for routine and nonroutine 10.4 – Counting 60-Day Episodes medical supplies. The six home health disciplines included in the 60-day A – Initial Episodes: The "From" date for the initial certification must match episode rate are: the start of care (SOC) date, which is the first billable visit date for the 60- day episode. The "To" date is up to and including the last day of the episode 1. Skilled nursing services which is not the first day of the subsequent episode. The "To" date can be up 2. Home health aide services; to, but never exceed a total of 60 days that includes the SOC date plus 59 3. Physical therapy; days. 4. Speech-language pathology services; B – Subsequent Episodes: If a patient continues to be eligible for the home 5. Occupational therapy services; and health benefit, the home health PPS permits continuous episode 6. Medical social services. recertifications. At the end of the 60-day episode, a decision must be made The 60-day episode rate also includes amounts for: whether or not to recertify the patient for a subsequent 60-day episode. An eligible beneficiary who qualifies for a subsequent 60-day episode would start 1. Nonroutine medical supplies and therapies that could have been the subsequent 60-day episode on day 61. The "From" date for the first unbundled to part B prior to PPS. See §10.12.C for those services; subsequent episode is day 61 up to including day 120. The "To" date for the 2. Ongoing reporting costs associated with the outcome and assessment subsequent episode in this example can be up to, but never exceed a total of information set (OASIS); and 60 days that includes day 61 plus 59 days. Note that the certification or recertification visit can be done during a prior episode. 3. A one time first year of PPS cost adjustment reflecting implementation costs associated with the revised OASIS assessment schedules needed to 10.5 – Split Percentage Payment Approach to the classify patients into appropriate case-mix categories. 60-Day Episode B – Excluded Services: The law specifically excludes durable medical In order to ensure adequate cash flow to HHAs, the home health PPS has set equipment from the 60-day episode rate and consolidated billing forth a split percentage payment approach to the 60-day episode. The split requirements. DME continues to be paid on the fee schedule outside of the percentage occurs through the request for anticipated payment (RAP) at the PPS rate. start of the episode and the final claim at the end of the episode. For initial The osteoporosis drug (injectable calcitonin), which is covered where a episodes, there will be a 60/40 split percentage payment. An initial woman is postmenopausal and has a bone fracture. This drug is also percentage payment of 60 percent of the episode will be paid at the beginning excluded from the 60-day episode rate but must be billed by the home health of the episode and a final percentage payment of 40 percent will be paid at agency (HHA) while a patient is under a home health plan of care since the the end of the episode, unless there is an applicable adjustment. For all law requires consolidated billing of osteoporosis drugs. The osteoporosis subsequent episodes for beneficiaries who receive continuous home health drug continues to be paid on a reasonable cost basis. care, the episodes will be paid at a 50/50-percentage payment split. 10.2 – Adjustments to the 60-Day Episode Rates 10.6 – Physician Signature Requirements for the Split A – Case-Mix Adjustment: A case-mix methodology adjusts payment rates Percentage Payments based on characteristics of the patient and his/her corresponding resource A – Initial Percentage Payment: If a physician-signed plan of care is not needs (e.g., diagnosis, clinical factors, functional factors, service needs). The available at the beginning of the episode, the HHA may submit a RAP for the 60-day episode rates are adjusted by case-mix methodology based on data initial percentage payment based on physician verbal orders OR a referral elements from the OASIS. The data elements of the case-mix adjustment prescribing detailed orders for the services to be rendered that is signed and methodology are organized into three dimensions to capture clinical severity dated by the physician. If the RAP submission is based on a physician's factors, functional severity factors, and service utilization factors influencing verbal orders, the verbal order must be recorded in the plan of care, include case mix. In the clinical, functional, and service utilization dimensions, each a description of the patient's condition and the services to be provided by the data element is assigned a score value. The scores are summed to determine home health agency, and include an attestation (relating to the physician's the patient's case-mix group. orders and the date received per Code of Federal Regulation (CFR) 42 CFR B - Labor Adjustments: The labor portion of the 60-day episode rates is 409.43). The plan of care is copied and immediately submitted to the adjusted to reflect the wage index based on the site of service of the physician. A billable visit must be rendered prior to the submission of a beneficiary. The beneficiary's location is the determining factor for the labor RAP. adjustment. The home health PPS rates are adjusted by the pre-floor and 2006 ICD•9•CM Resources — 5