August 2016
Hospice Coding Left Out?
By Shawna Zastoupil, RHIT
Like many other healthcare settings, hospices are starting their journey into coding compliance. Before the first Federal Regulation (FY 2013), which addressed diagnosis coding clarification, hospices typically reported one code on their claims. Since that time, the Department of Health and Human Services has submitted more regulations regarding diagnosis coding for hospices. New federal regulations from the Centers for Medicaid and Medicare Services were finalized to assist in clarification of hospice coding. However, many hospice coders found additional questions when trying to apply the guidance. This article examines some of those questions and offers possible answers.
Acute Care Diagnosis Codes in Hospice?
Hospice coding professionals have been divided by a debate regarding diagnoses typically seen in the acute care facility. Some coders question if these acute care codes should be used in hospice.
As coding professionals, we cannot make assumptions or rush to conclusions. Instead, we need to go back to the "basics," and review the Coding Guidelines. That said, the Coding Guidelines only instruct us on when to use "acute" care codes for particular disease processes, not for the location or facility using the codes. The following example demonstrates when an acute condition is used in hospice:
Patient appeared suddenly weak and was taken to the emergency department (ED). An MRI demonstrated an acute cerebral hemorrhage. The family and patient decided to forgo treatment and the patient was admitted from the ED to hospice. The certifying physician stated the hospice terminal diagnosis was acute brain hemorrhage. The sequela is not documented and the certifying physician stated that the cause of demise will be the bleed.
In this case, the acute cerebral hemorrhage demonstrates the terminal diagnosis code for this hospice patient.
7th Characters: Where Does Hospice Fit?
In the case of pathological fractures, a 7th character is required to complete the code. The 7th character may be:
7th Character
Initial encounter for fracture
Subsequent encounter for fracture with routine healing
Subsequent encounter for fracture with delayed healing
Subsequent encounter for fracture with nonunion
Subsequent encounter for fracture with malunion

In an example of a hospice patient with Alzheimer's dementia, suffering from a pathological (osteoporosis) fracture of the spine, what 7th character would be hospice-appropriate?
Many post-acute care coding discussions state that the 7th character "D" is the default. However, does "routine healing" in the definition of the 7th character "D," "subsequent encounter for fracture with routine healing," really fit into hospice?

The Coding Guidelines state, "7th character D is to be used for encounters after the patient has completed active treatment. The other 7th characters, listed under each subcategory in the Tabular List, are to be used for subsequent encounters for treatment of problems associated with the healing, such as malunions, nonunions, and sequelae."1 Thus, the subsequent encounter is for treatment; in hospice we are not usually treating the fracture. Or, should comfort care be considered a "treatment"?
Other coding professionals discuss the use of "S," sequelae, because the patient is primarily a hospice patient. However, we are left with a conundrum when no sequelae are listed or linked by physician documentation to justify the "S" character.
Diabetes Assumption with HTN CKD Ruling for Terminal Patients
The Coding Guidelines state that coding professionals should assume a relationship between hypertension and chronic kidney disease (CKD). This was a rule from ICD-9 and carries over in ICD-10. Recently, Coding Clinic issued a new assumption rule that a relationship between diabetes mellitus (DM) and CKD should be assumed.2
When it comes to the terminal diagnosis of CKD in a patient who has both documented hypertension and DM, hospice coding professionals have started to query the physician on which condition has greater impact on the CKD. Unfortunately, this is an area where many certifying physicians and medical directors are in a quandary. The difficulty of determining which underlying disease is primarily affecting the CKD in a patient with a terminal diagnosis in the hospice setting is a scenario that seems to not to have been considered when Coding Clinic determined the new DM assumption rule.
In the end, hospices will need to lean on medical directors and certifying physicians to determine the underlying cause of the CKD.
In our facility, we have developed the following template to assist coding professionals:
Suggested Terminal Diagnosis;
Please select:
Terminal code
Secondary codes
Hypertensive CKD
E11.2- or E10.2-
Diabetic CKD
E11.2- or E10.2-
ICD-10 has stirred up many questions for all coding professionals. Guidance from Coding Clinic in the future should be able to assist hospice coding professionals. In the meantime, it is helpful to get back to basics by reviewing the Coding Guidelines and coding manual notes.
Finally, as the ICD-10 Official Guidelines for Coding and Reporting states,"The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task."3 Hospices should build a strong rapport with referral agencies to assist with complete, consistent documentation.
1. Centers for Disease Control and Prevention: "ICD-10-CM Official Guidelines for Coding and Reporting: FY 2016" Section I, Conventions, General Coding Guidelines and Chapter Specific Guidelines II, C. Chapter Specific Coding Guidelines, 13.b Coding of Pathological Fracture.
2. American Hospital Association. AHA Coding Clinic for ICD-10-CM, no. 2 (Second quarter, 2016).
3. ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Section II. Selection of Principal Diagnosis.
Shawna Zastoupil, RHIT, is coding manager at Corridor Hospice, in Bismarck, ND.