Transcript Medicare and SNF

Medicare Documentation &
ICD-9-CM Coding
Presented by
Rhonda Anderson, RHIA
President
Anderson Health Information Systems, Inc.
714-558-3887
[email protected]
Presented To
Healthcare Management Services, LLC
1332 S. Glendale Ave.
Glendale, CA 91205
February 3, 2010
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
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Transfer Records
History & Physical
Progress Notes
Admission Orders
Additional Sources of
Information
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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 -2
• 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
Thanks for attending