1. Diagnosis Assignment Sequencing and Coding for Long Term Care
Presented by:
Lizeth Flores, RHIT
Anderson Health Information Systems, Inc.
940 W. 17th Street, Suite B
Santa Ana, California, 92706
Tel. (714)

2. Objectives Participants will:
Correctly identify primary / Secondary diagnoses
Be able to abstract diagnoses from transfer documentation
Be able to relate primary admission diagnosis to Medicare Qualifying stay
Correctly sequence diagnoses for coding assignment

3. We are changing our practice

4. Requirements
Official coding guidelines require the use of V codes for aftercare and specify that applicable aftercare V-codes are to be used for conditions requiring continued / long term care or healing phase of a condition/disease.
The official coding guidelines are developed by CMS (Centers for Medicare and Medicaid Services) & NCHS (National Center for Health Statistics) and updated in October and April of every year.

5. 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
2. For example when a resident is admitted for physical therapy (aftercare) following a hip fracture (V57.1 physical therapy, V54.13 fracture, hip, healing, traumatic)
3. For example aftercare for healing traumatic facture of upper arm (V54.11), status post prostatectomy for BPH (V58.76)

6. 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

7. Not So New Coding clinic Fourth Quarter 1999
Published rules for the use of V codes
Addressed the use of V codes in LTC settings
Coding clinic Fourth Quarter 2003
Clarified the use of aftercare V codes for all subsequent encounters after the initial treatment for a fracture
“for statistical purposes, a facture should only be reported once”

8. CMS Manual System Transmittal 437
Principal Diagnosis Code - SNFs enter the ICD-9-CM code for the principal diagnosis in FL 67. The code must be reported according to Official ICD-9-CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes. The code must be the full ICD-9-CM diagnosis code, including all five digits where applicable.
Other Diagnosis Codes Required – The SNF enters the full ICD-9-CM codes for up to eight additional conditions in FLs Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-9-CM guidelines.

9. PRINTED IN MAY 05 CHIA Journal © Insights to Coding and Data Quality CMS confirms use of V-codes on UB 92 for SNF billing by Ann G Uniack, RHIA Member, Coding and Data Quality Committee The Center for Medicare and Medicaid Services (CMS) has confirmed that SNFs must use the correct ICD-9-CM codes including V codes on the UB-92 for Medicare billing. Transmittal 437 adds the following to Pub Medicare Claims Manual, Chapter 6, Section 30, Billing SNF PPS Services. The CMS online transmittal can be accessed on the Internet at: <

10. So What’s Changing???

11. CVHS will begin implementation of the use of V-codes for principal diagnoses in compliance with official coding guidelines effective October 2009 with full compliance by November 1st 2009

12. What this means to you
The Principal diagnosis will no longer be an acute diagnosis and it may be a V-CODE
800.XX codes for fractures will NO LONGER be used

13. What you need to do
When sequencing diagnoses upon admission you must keep in mind that acute diagnoses will no longer be part of the diagnosis listing
Identify aftercare diagnosis statements and sequence appropriately

14. What if….. Could the facility face claim denials due to this change?
NO – the FI is well aware of the ICD-9-CM coding guidelines and requirements.

15. Ready ……..Set…….Go

16. Definition of 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.”
Medicare – To be covered the extended services must be for the treatment of a condition for which the resident received inpatient hospital services during the 3-day qualifying stay

17. Guidelines: the coder should make every effort to record the codes in logical sequence that is descriptive of the patient’s condition

18. V Codes as principal diagnosis
V Codes may be listed as a principal or secondary diagnosis as stated in official coding guidelines
V Codes are used in both inpatient and outpatient setting
V Codes indicate a reason for an encounter

19. Using V Codes in post –acute care settings
When a person is not currently sick encounters the health services for some specific reasons
( e.g. organ donor, inoculations, healthcare screenings, etc. )
When a person with resolving disease or injury, requiring continuous care (e.g. dialysis for renal disease, chemotherapy for malignancy, cast change, etc. )
When circumstances influence a persons’ health status but are not in themselves a current illness or injury

20. Type 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.

21. Type of Codes…………
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.

22. Medicare diagnosis needs to be consistent with covered services & MDS.
Explain a covered services here and make a slide too…..
AHIS, Inc / 22

23. MEDICARE Resident must have a 3-day qualifying hospital stay.
Physician must certify the need for skilled services.
Skilled services must be related to the condition treated during the qualifying 3 day hospital stay.

24. EXAMPLES
1. Resident was treated for UTI at the hospital and is still on IV antibiotic therapy.
2. Resident had surgery for a bowel obstruction and needs care to the surgical site and physical / occupational therapy

25. 1. UTI can be the primary diagnosis since Resident is still receiving ATB therapy
2. Primary diagnosis would be aftercare following surgery to the digestive system, secondary diagnosis may be admission for multiple therapies

26. What to Code?
ALL CONDITIONS THAT EXIST AT THE TIME OF ADMISSION, THAT EFFECT TREATMENT RECEIVED

27. 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)

28. Locating the Principal Diagnosis

29. Where are the diagnoses???
Transfer Records
History & Physical
Progress Notes
Admission Orders

30. Discharge summary
Transfer documentation
Surgical reports
Consultations
Physician Progress notes
Lab reports and radiological studies

31. Principal Diagnosis
When two or more inter-related conditions potentially meet the definition of principal diagnosis
Either may be sequenced first unless therapy is being provided, the Tabular list or Alphabetic Index indicate otherwise.
Inter-related conditions – two or more diagnosis that equally meet the definition of principal diagnosis.

32. Example
Resident admitted with Pneumonia and UTI – either can be used as the principal diagnosis if the resident is still receiving antibiotic therapy

33. Choose the Principal Diagnosis
Fall 3 months ago
Chronic kidney disease
Above the knee amputation Rt. Leg 10 days ago
Anemia
MRSA of surgical wound
(resolved)

34. Diagnosis Sequencing
The order in which codes are listed is called sequencing.
Every effort should be made to record the codes in a logical sequence that is descriptive of the resident’s condition.

35. Choose the correct sequence
Diabetes
Fx left forearm due to fall last week
UTI (on antibiotics)
Chronic Back Pain
Hyperlipidemia

36. Acute Diagnoses
Acute dx treated in the hospital should be coded until the condition is resolved, after the resident is transferred to the SNF
Examples:
MRSA
Pneumonia
UTI
CVA

37. V-Codes
V-codes are assigned to problems that affect the patient’s health but are not in themselves a current illness or injury
V-codes can be used to represent status or history.
Examples:
Status Cardiac Pacemaker V45.01
Status heart valve prosthesis V43.3
History of falls V15.88
CABG V45.81
Remember not to use acute care codes when coding aftercare

38. Aftercare are used when the initial treatment has been performed but the patient continues to need care during the healing / recovery phase
Examples:
Aftercare following surgery
Physical and/or occupational therapy
Aftercare for healing traumatic fracture

39. To “V” or not to “V” Scenario # 1
A resident is admitted for physical therapy following a hip replacement for an inter-trochanteric right hip fracture due to a fall.

40. To ‘V’ or Not to ‘V’: Scenario #1
Physical therapy:
V57.1 Physical Therapy
Intertrochantic right hip fracture due to a fall:
V54.13 Aftercare following traumatic hip fracture
Hip replacement:
V54.81 Aftercare following joint replacement
V43.64 Joint replacement, hip

41. To ‘V’ or Not to ‘V’: Scenario #2
A resident is admitted for P.T. & O.T.
following a hip fracture after a fall.
The physician indicated that the fracture was due to osteoporosis. The Discharge Summary stated that old compression fractures of the vertebrae due to osteoporosis were present on x-ray.

42. To ‘V’ or Not to ‘V’: Scenario #2
Physical Therapy and Occupational Therapy
V57.89 Multiple therapies
Hip Fracture (due to osteoporosis)
V54.23 Aftercare for continuing treatment of healing pathologic fracture of hip
Osteoporosis
Osteoporosis
Compression fractures of vertebrae
Pathologic fractures of vertebrae

43. Combination Codes
A single code used to classify TWO (2) diagnoses or a diagnosis with an associated manifestation or complication.
Key words:
“AND”, “AND/OR”
“WITH”, “WITH MENTION OF” OR “ASSOCIATED WITH”
“EXCLUDES”

44. Let’s Practice 1. Chronic Peptic Ulcer with Hemorrhage
2. Cerebral thrombosis with cerebral infarction
3. Diverticulitis of Duodenum “with” bleeding

45. Manifestation Codes
There are written instructions in ICD-9-CM coding books for sequencing codes.
The underlying Dx (cause/s) coded first, followed by codes for manifestations.

46. Manifestation Codes Diabetic Neuropathy
Diabetes with neurological manifestations must be coded first (250.60)
The tabular list will guide you to “Use additional code to identify manifestation, as:”
Polyneuropathy in diabetes (357.2)
The tabular section will tell you that this code is not allowed as a principal Dx and will guide you to code underlying disease, as (Diabetes with complication…)

47. Example
1. ALZHEIMER’S DEMENTIA
2. DIABETIC GLAUCOMA

48. Multiple Coding Examples: Aftercare following kidney transplant
V58.44 (aftercare involving organ transplant),
V42.0 (Organ/tissue replacement by transplant , kidney)
Aftercare following arteriocoronary bypass
V58.73 (aftercare following surgery of the circulatory system), V45.81(aortocoronary bypass status)
 use aftercare codes to provide better detail

49. Coding Diabetes
Metabolic manifestations of the disease – require only one code
Example:
Diabetes with ketoacidosis 250.1x

50. Combination Codes Some Diabetic Conditions Require 2 Codes
“Diabetic” or “Due to”
One Code for Cause
One Code for Complication
Always sequence cause before complication

51. Combination Codes Example: Diabetic foot ulcer
Diabetes with other manifestation
250.8x
Ulcer of lower limb, except decubitus
707.1x

52. Be Patient
Once you have sequenced the diagnoses and the MRD is ready to code all of this information can get very confusing and you may be asked for clarification.
We appreciate your patience, working together will help ensure compliance with regulatory guidelines as well as maintain the accuracy of our Residents’ medical records

53. Skin Ulcers of the Lower Limbs
Non pressure ulcers of lower leg
Fifth digits to identify site
Multiple coding, code first the underlying dx, such as arteriosclerosis, diabetes, venous hypertension
i.e. diabetic ulcer of left fifth toe ,

54. Myocardial Infarction
A code from category 410.XX must be assigned if the admission is strictly for rehabilitation within eight weeks of the acute MI.
The fifth digit 2 would be used in LTC to designate observation, treatment or evaluation of MI within eight weeks of onset, following the acute phase or in the healing state.

55. Myocardial Infarction
The fifth digit “1” should be used if the acute myocardial infarction occurred at the nursing facility and was the reason for transfer to the hospital or the cause of death.
If the admission takes place after eight weeks assign code (412) Old Myocardial Infarction

56. Neoplasms with Metastasis
Two codes
One for primary (original site)
One for each secondary site
Please be as specific as possible when listing the diagnoses

57. Unknown Secondary Sites
Ex: Cancer of Lower lobe of lung with metastases (162.5, 199.0)
Primary site will be coded first
An code for Unknown secondary site will be assigned to the metastasis

58. Unknown Primary Site
The site of the metastasis will be sequenced first
The unknown primary site will be assigned an “unknown site” code and sequenced after secondary site(s)
Ex: abdominal metastasis from unknown origin (198.89, 199.1)
Unknown primary would not be used as principle diagnosis in SNF
The metastatic site is coded first

59. V-Codes for Neoplasms Primary site must still be identified
If removed, eradicated no longer under treatment
Use a personal history V-code, History,site, malignant neoplasm
Using this V-code will identify primary site responsible for metastasis that is no longer present

60. V-Codes for Neoplasms
Do not use codes from category V10 for secondary metastatic sites removed or not
ICD-9-CM does not provide code numbers for “history of secondary neoplasm site

61. V-Codes for Neoplasms A primary malignancy
Previously excised or eradicated from its site
And there is no further tx directed to that site
And there is no evidence of any existing primary malignancy,
A code from Category V10 is used to identify the former site of malignancy

62. V-Codes for Neoplasms
V12.41 Personal history of benign neoplasm of the brain.
Previously, no code to indicate that the patient had benign growth. These can cause serious symptoms in the patient.

63. V58.42 Neoplasm
Official coding guidelines for neoplasm apply when using the aftercare following surgery for neoplasm V58.42
Aftercare code V58.42 may be used with either the current neoplasm code or a code from category V10, whichever is applicable

64. Late Effects of CVA ( )
Rather than code the residual condition AND the late effect, combination codes that include the late effect should be used. Additionally, these can be used with a new CVA.
DO NOT code 436 for CVA codes from categories are used for the initial episode of care for an acute CVA at the hospital

65. Late Effects…..
The residual condition is coded first and the late effect is sequenced second
Multiple coding is required for most late effects
A late effect is not used as a principal dx, except for Category 438 Late Effect of CVA
i.e. Left Hemiplegia due to CVA

66. 438 Late Effects of CVA
Official coding guidelines state that Category 438 is used for admission and encounter for post acute care following treatment of the CVA in the acute hospital
Codes from categories 430 to 436 are reserved for the “initial” (first) episode of care for an acute CVA that was provided in the qualifying hospital stay and should not be used in SNF

67. 438 Combination / Multiple Coding
Category 438 includes combination codes that describe both the cause and the residual deficit
Right hemiplegia due to old CVA
More than one code my be used from category 438 to identify multiple residuals from a CVA
Dysphagia and left hemiplegia post CVA ,

68. 438
Use additional codes with category 438 if the combination code does not address all elements of diagnostic statement
Multiple coding is used to identify residuals of CVA that do not have a specific code
Seizure disorder following CVA ,

69. Aftercare for Healing Traumatic Fracture
For residents admitted to a SNF for care following treatment in the acute hospital for a traumatic fx use the aftercare codes from Subcategory V54.1
code the (acute) fracture to explain the subsequent V-code for aftercare
Coding Guidelines require an aftercare code be used after the initial encounter for care of a fx.

70. Aftercare for Healing Pathological Fracture
To assist in accurate coding assignment; as much as possible, be specific as to the nature of the fracture
Traumatic vs. Pathological

71. Joint Replacement
Joint replacement of knee for osteoarthritis (V58.78), V54.81, V43.65
Coding guidelines direct not to code the disease condition that was treated with the surgery

72. Joint Replacement for Fracture
Use multiple coding to fully describe the resident’s condition
Example:
FX hip (traumatic) with joint replacement V54.13, V54.81, V43.64

73. V57 – Care Involving Rehab
Category V57 does not indicate that rehab services were provided, only that the resident was admitted for this purpose

74. Aftercare Following Surgery
The acute dx for which the surgery was preformed is not reported for aftercare encounters or admissions but is to be listed as the principal diagnosis in order to link the LTC services to the qualifying stay and as further explanation of the after care code to follow.
Use other aftercare or symptom codes to provide better detail

75. Heart Conditions due to HTN
When there is a casual relationship is states as “hypertensive” or “due to hypertension” heart conditions are assigned by Category 402 Hypertensive Heart Disease
Arteriosclerotic disease due to hypertension

76. Pressure Ulcer Use add’l code to identify pressure ulcer stage
pressure ulcer, unspecified stage
pressure ulcer, stage I
pressure ulcer, stage II
pressure ulcer, stage III
pressure ulcer, stage IV
pressure ulcer, unstageable

77. 2009-2010 code updates effective 10/1/09
Complete list of new, deleted and revised codes can be found in the shared folder
All facilities are required to begin using the 2010 coding books effective 10/1/09

78. Questions for discussion

79. Thanks for Attending
AHIS, Inc / 79

80. Other TIPS
If V57.89 is already on the list, no need to add separate rehab services (e.g. V57.1)
707.0 (should no longer be unspecified)
Use specific coding such as PS uns. Stage
PS Stage 1
PS Stage 2
PS Stage 3
PS Stage 4

81. Other TIPS 787.2 (Dysphagia) no longer valid, need to use
Dysphagia, unspecified
Dys[hagia, oral phase
Dysphagia, oropharyngeal phase
Dysphagia, pharyngeal phase
etc

82. Principal Diagnosis
Condition chiefly responsible for resident’s admission to the nursing facility
Diagnosis which provides reason for resident remaining in the nursing facility
Do not use acute codes or procedural codes
Acute MI
CVA
Hip fracture
Arthroplasty

83. Sequential Diagnosis Sequencing of secondary diagnosis
Code for other co-morbidities
Code clinical conditions that arose while in the SNF
Affect treatment the resident is receiving or the resident’s length of stay
Currently no guidelines provided on sequencing of secondary diagnosis

84. Coding Exercise
Resident admitted to your facility following a CVA resulting in left sided hemiparesis(resident is right handed), dysphagia requiring a G Tube. Resident also has diabetes receiving daily insulin injections and will be receiving PT, OT and SLP therapy services

85. ICD 9 Codes V57.89 care involving use of rehabilitation, multiple
– late effects of CVA. Dysphagia
– Dysphagia unspecified
– Late effects of CVA, hemiplegia affecting non dominant side
V44.1 – Artificial opening status ; gastrostomy
– DM II without mention of complication
V58.67 – Long Term (current) use of insulin

86. Coding Exercise
Resident admitted to your facility after repair of a fractured hip (hip replacement) sustained due to a fall at home. Resident has history os ASHD (no surgery) and controlled atrial fibrillation and is on coumadin therapy. Resident will be receiving PT and OT services while in your facility. Pt/INR will be checked weekly and coumadin adjusted per MDS orders

87. ICD 9 Codes
V57.89 Care involving use of rehabilitation services (multiple therapy)
V54.81 – aftercare following joint replacement
V43.64 – organ or tissue replace by other means (hip joint)
– coronary atherosclerosis of native artery
– Atrial fibrillation
V58.83 – encounter for therapeutic drug monitoring
V58.61 – long term (current use) of anti coagulants

88. Coding Exercise
Resident admitted to your facility following abdominal surgery for bowel obstruction. Resident has partially opened surgical wound requiring daily dressing changes. Resident also has UTI (E.Coli) and is on ATB. Resident will not be receiving therapy until the wound has healed. Residents otherwise has no other significant health history

89. ICD 9 Codes
Disruption of external operation wound (dehiscence of operation wound)
V58.75 – aftercare following surgery of the teeth, oral cavity and digestive system, NEC
V58.31 – attention to surgical dressings and sutures
599.0 UTI, site not specified
041.4 – E.Coli

90. Coding exercise
Ms. Beth Logins is an 83 year old with type II diabetes and prepheral vascular diasease (PVD). He was admitted to the hospital for a left below the knee amputation sue to the PVD, secondary to DM. She was transferred to the SNF to recover after surgery. Ms. Loggins will have both PT and OT

91. ICD 9 Coding Principal Diagnosis – V57.89 Secondary
V54.89 – aftercare for amputation stump
V49.75 lower limb amputation, below knee
– DM with peripheral circ disorder
PVD secondary to type II