Hospice ICD-10 Coding

There are a lot of different areas of expertise in the world of ICD-10 medical coding, including Inpatient, Outpatient, Home Health, and Hospice. Each area has specific rules and regulations, which makes it important to review all conventions and guidelines for each code that is being added to a claim. Just like all the other areas, Hospice ICD-10 coding has its own set of rules. Keep reading to learn more. 

SCHEDULE A MEETING to get started with our full service hospice coding services

Primary diagnosis can impact hospice eligibility

In order to be eligible for hospice services, the physician must document a Certificate of Terminal Illness (CTI) that states that the patient has a prognosis of six months or less if the terminal illness runs its normal course. In addition, the CTI must contain the primary diagnosis.   The primary diagnosis is the diagnosis that most contributes to the terminal condition. If the physician lists a manifestation diagnosis as the terminal illness on the CTI, CMS hospice billing guidelines and ICD‐10‐CM official coding guidelines must still be followed. The appropriate etiology code must be listed as the primary diagnosis, followed by the manifestation code indicated as the terminal condition. A note should then be placed in the patient chart to account for why the primary diagnosis on the care plan does not match the initial CTI form. 

Should all known diagnoses be listed on a hospice claim?

Up to 25 diagnoses may be coded on a hospice claim, and all diagnoses that are listed must be confirmed by the physician. All current or active diagnoses, both related and unrelated to the terminal illness must be listed on the hospice claim, so it is important to make wise use of the diagnosis real-estate available with just 25 slots.  

It is the responsibility of the Medical Director to document how any diagnosis listed is NOT related. This is usually decided during the Interdisciplinary Group (IDG) meetings, which is a meeting of the entire team responsible for the holistic care of the hospice beneficiary. Keep in mind that historical codes that capture past medical history are not current/active diagnoses, and they do not need to be listed unless the historical condition has an impact on the current care or influences treatment. In addition, conditions that no longer apply once the patient is in the terminal stages of life, such as erectile dysfunction should not be listed. Often a patient may be diagnosed with a mass that the MD describes as “likely malignancy” and the patient chooses not to pursue confirmation. In this case the agency would need to focus on the symptoms, as suspected, probable, likely, or other similarly described uncertain conditions cannot be listed unless confirmed by the MD.

What does not qualify as a primary diagnosis on a hospice claim?

Hospice has several  topic-specific rules when it comes to ICD-10 coding.   Many of those rules apply to Dementia, Malnutrition, CVA, and Fractures.   A few things that will catch the eye of an auditor really quickly and result in a denial is coding “Debility” or “Adult Failure to Thrive” as the primary terminal illness.   Both of these diagnoses may contribute to getting a patient to their final destination faster, but both of these are nonspecific symptoms, which are typically the result of a more defined disease process (aka the etiology) that should be captured as the primary diagnosis.   Another red flag that will stop you dead in your tracks, is if a diagnosis such as Osteoarthritis is listed as the primary focus.   Osteoarthritis can result in a lot of pain and loss of mobility but it is not considered a terminal condition.  

In addition, there are a multitude of diagnoses that are considered invalid primary diagnosis on hospice claims.  Many of the conditions are directly related to dementia, mood, and personality disorders and are clearly dictated in hospice ICD-10 coding guidelines.  

Who is responsible for confirming accuracy?

Ultimately, when reviewing the accuracy of the diagnoses on a hospice claim, an individual must look at the factors surrounding a condition and determine how it is contributing to the terminal prognosis.   This may not always be clear to the individuals saddled with assigning the diagnosis codes.   Although agencies are responsible for ensuring eligibility, it is ultimately the responsibility of the Medical Director and the IDG team to use their collective knowledge and experience to determine what diagnoses actually are currently active for each patient, and provide definitive documentation to support accurate hospice ICD-10 coding.