Medicare Documentation & ICD-9-CM Coding

Presented by

Rhonda Anderson, RHIA

PresidentAnderson Health Information

Systems, Inc 714-558-3887

office@ahis.net

Certifications Timeliness

• The initial certification is completed on or prior to admission for Medicare coverage.

• Within 72 hours of admission;• On the day the physician visits the resident and writes

the first progress note;• On the Interfacility Transfer form as an alternative to

completing the initial certification.• The facility is responsible for obtaining timely and

complete certification/re-certifications. • Re-certifications are due on or before the 14th day of

admission, and every 30 days after that until coverage ends

Daily documentation

• Supporting documentation should be consistent and reflective of MDS responses

• Standard of practice requires documentation of care and services delivered and resident’s response to care and services provided

Vulnerabilities

• Incomplete documentation (charting omissions)

• Unsigned physician orders

• Inaccurate documentation of indirect nursing services as this is not part of MDS information and can only be supported by nursing documentation

Evidence of skilled level services

• If resident is receiving therapy services

• Nursing documentation must describe resident’s level of activity with nursing staff, participation in therapy and reflect nursing activities that support rehab statements and goals

ICD-9-CM Coding

Purpose of ICD- 9-CM Coding

• Gather statistical data• Reporting diagnoses and provides a

method for sequencing diagnosis to support reimbursement

• Ensure compliance with Federal Reporting Standards for diagnoses

• Provide insight into the types of residents and conditions

• Health Research

Requirements

• Per ICD-9-CM Official Guidelines for Coding and Reporting, aftercare codes are generally first to explain the specific reason for the encounter (admission)

• Certain aftercare code categories need a secondary dx code to describe the resolving condition or sequelae

• For others (V codes) the condition is inherent in code title

Fiscal Intermediary

• The FI will not accept V-codes as principal diagnosis - is an INCORRECT statement.

• The Principal DX must be reported according to Official ICD-9-CM guidelines for coding and reporting, as required by HIPAA including any applicable guidelines regarding the use of V-Codes

Determining the principal diagnosis

• FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admissions to, continued residence in the nursing facility and the diagnosis that support the reimbursement and should be sequenced first.”

Locating Principal Diagnosis

Locating Diagnosis

• Transfer Records

• History & Physical

• Progress Notes

• Admission Orders

Additional Sources of Information

• Discharge summary• Transfer documentation, • Surgical reports• Consultations

• Physician Progress notes • Lab reports and radiological studies

Types of codes used in LTC

• Aftercare – used when the initial treatment of a disease or injury has been performed and the patients still requires continued care to heal or recover.

• Late Effects – a late effect is a residual condition that remains and requires medical evaluation, rehab treatments and/or nursing care after the initial illness or injury.

Types of Codes -3

• History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter.

• A history code is distinct from a “status” code in that history codes indicate that the patient no longer has the condition and “status” codes indicated a present state.

• There are two types of history V-codes, personal and family.

Types of Codes -3

• History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter.

• A history code is distinct from a “status” code in that history codes indicate that the patient no longer has the condition and “status” codes indicated a present state.

• There are two types of history V-codes, personal and family.

Medicare

• Medicare diagnosis needs to be consistent with covered services & MDS.

Diagnosis Sequencing

• The order in which codes are listed is called sequencing. The coder should make every effort to record the codes in a logical sequence that is descriptive of the resident’s condition.

What to Code?

ALL CONDITIONS THAT EXIST AT THE TIME OF ADMISSION, THAT EFFECT

TREATMENT RECEIVED

Do NOT Code

• DIAGNOSES THAT DO NOT AFFECT TREATMENT OR LENGTH OF STAY

• WHEN CONDITION NO LONGER EXISTS

• DO NOT ASSIGN PROCEDURE CODES

• Examples: Fractured forearm 6 years ago, pneumonia, UTI that were resolved (these will only be coded if the Resident is admitted with Antibiotics)

V57 Care Involving Rehab

• Category V57 does not indicate that rehab services were provided, only that the resident was admitted for this purpose

• Use only one code from Category V57 for an admission

• If the resident is admitted for multiple therapies, use V57.89

V57 Care Involving Rehab -2

• Code also the condition requiring the rehab, such as:– Residuals– Late effects– Aftercare– symptoms

ICD-9-CM Official Guidelines for Coding & Reporting

• www.cdc.gov/nchs/data/icd9/cdguide.pdf

• Latest Revision October 1, 2009

• Codes revised twice per year April and October

• April codes will come out only if significant or important and can not wait until October

Questions and Answers

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