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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

Hospice Coding Clarifications

Special thanks to Judy Adams, RN, BSN, HCS-D, Approved AHIMA ICD-10-CM Trainer with Adams Home Care Consulting, Inc., Asheville, NC,, for her contribution of the following article
October 25, 2013 03:07 PM

The article below assists hospices in determining which diagnosis codes are appropriate for use as the principal diagnosis on hospice claims. Please note that the Centers for Medicare & Medicaid Services (CMS) indicated in the Final FY2014 Hospice Wage Index and Payment Rule that hospice claims with adult failure to thrive (AFTT) or debility listed as the principal diagnosis will be returned to provider (RTP’d) beginning October 1, 2014.

In a routine review of CMS publications, The National Association for Home Care & Hospice (NAHC) and its affiliate, the Hospice Association of America (HAA) found direction from CMS to Medicare administrative contractors (MACs) to RTP all hospice claims with manifestation codes (not just debility or AFTT) listed as the principal diagnosis beginning Oct. 1, 2013. Since that time, CMS has indicated that the instruction directing the MACs to reject hospice claims using any manifestation code as the principal diagnosis should not have been issued and that the MACs have been instructed to turn that particular systems edit off.

NAHC/ HAA has confirmed with CMS representatives that CMS “is considering” a policy under which a hospice claim that includes ANY manifestation code as the principal diagnosis would be RTP’d.

NAHC/HAA anticipate that this is the direction CMS will provide to MACs as October 1, 2014 draws near. NAHC/HAA take this opportunity to remind hospice providers that even though claims will not be RTP’d until next year, hospices are required to comply with ICD-9-CM coding guidelines now and, as the article below instructs, manifestation codes are not to be used as the principal diagnosis.

The Final FY2014 Hospice Wage Index and Payment Rule included a considerable amount of information related to proper coding for hospice providers. The greatest emphasis was on the need for expanded coding of all conditions related to (contributing to) each patient’s terminal prognosis and compliance with the Official ICD-9-CM Coding Guidelines. In this article, I will address two primary topics: the guidelines and sequencing of etiology/manifestation codes and proper coding for dementia.

Etiology/Manifestation Coding Convention
(Section I.A.6. ICD-9-CM Official Coding Guidelines for Coding and Reporting, Effective October 1, 2011.)

Certain conditions have both an underlying etiology (or cause) and potential for multiple body system manifestations (complications) that are due to that underlying etiology. For these conditions, the ICD-9-CM has a coding convention that requires the underlying condition (the etiology) be sequenced first followed by the manifestation(s). In most situations, the manifestation code will have the phrase, “in diseases classified elsewhere” in the code title and an instructional note to “code first the underlying condition.” Since the manifestation codes can never be listed in the first or principal diagnosis code position, they generally have additional indicators in the Tabular List to identify them as manifestation codes (e.g., the title is in italics, the code is highlighted in color and/or may have a symbol defining it as a manifestation code).

Additionally, there are some manifestation codes that do not have “in diseases classified elsewhere” in their title. In these situations there may be a “use an additional code” notation present in the Tabular List and the rules of sequencing apply. Etiology/manifestation combination codes also have a special Alphabetical Index entry structure in which both conditions are listed together with the etiology code listed first and the manifestation code listed right after it, but enclosed in brackets.

The most commonly used etiology/manifestation combination codes are used for Diabetes mellitus, category 250, (e.g., diabetic end stage renal disease: 250.40 [585.6]) However, there are etiology/manifestation codes available in nearly every chapter of the Tabular List in the ICD-9-CM coding manual.

And lastly, “code first” and “use an additional code” notes are used as sequencing rules for certain codes that are not part of an etiology/manifestation pair. An example of this classification of codes is an infection with a note to use an additional code for the infectious organism. (See Section I.B.9, Multiple coding for a single condition in the ICD-9-CM Official Coding Guidelines effective 10/1/2011).

Dementia Codes

To assign a dementia code, there must be a specific diagnosis listed on a physician summary or report in the medical record or clinician documentation of a communication with a physician who confirms/verifies the specific type of dementia that the patient has. To find the correct dementia code, the coder must begin the search in the Alphabetical Index under the key word dementia and then verify the correct code in the Tabular List.

Dementia codes can be found in several chapters of the ICD-9-CM manual as follow:

  • Mental, Behavioral and Neurodevelopmental Disorders
  • Diseases of the Nervous System
  • Infectious Disease

Some dementia codes are clearly indicated in the Tabular List as etiology/manifestation codes when they are due to underlying neurological conditions such as Alzheimer’s Disease, Parkinson’s Disease, Lewy bodies, epilepsy, etc; infectious nervous system diseases such as Syphilis, HIV, Jacob-Creutzfieldt disease; and other conditions affecting nerves such as polyarteritis nordosa, etc.

All of these conditions are listed in the Alphabetical List with two codes with the etiology listed first and the dementia code (294.10 or 294.11) listed in brackets following the etiology code. The 5th character “0” indicates without behavioral disorders and “1” with behavioral disorders.

In 2011, a new dementia code, 294.2x, was approved and added. This code is used when a patient is determined to have dementia, but it is unspecified and the physician cannot link it to any particular underlying condition. The 5th digit will be a “0” if without behavioral disorders or a “1” with behavioral disorders.

Another group of dementia codes are found in the 290-295 categories. When checking these codes in the Tabular List, you will find instructional notes at many of these codes to code first the associated neurological condition, if known at category 290, or use an additional code to identify cerebral atherosclerosis at 290.4, vascular dementia, or use an additional code for any associated drug dependence and an E code to identify the drug at 292, etc. So read carefully any notes under the category or subcategory term. For example, while the note at 290 states to code first the associated neurological condition, it also states that sometimes the associated neurological condition is not documented, but if documentation indicates presenile or senile dementias, the appropriate 290 codes should be used.

In the FY2014 Final Wage Index and Payment Rule, CMS speaks to hospices coding a number of dementia codes as primary codes on the hospice claim that are not appropriate principal diagnoses. The two that they identified as the most common were senile dementia uncomplicated (290.0) and other persistent mental disorder due to conditions classified elsewhere (294.8). The Senile dementia 290.0 code is very vague and I believe CMS’ concern is that this code would generally not be the main contributing factor to the terminal condition plus it has a note indicating the provider should code first the associated neurological condition.

There are some additional, more specific senile dementia codes that might be more appropriate to use. 294.8 was the default code for an unspecified dementia prior to 2011, but then 294.2x was added plus any dementia due to a condition classified elsewhere is correctly coded to 294.1x instead. It is important to remember as well that the physician or nurse practitioner establishes diagnoses and the rule does emphasize that the decision for hospice diagnoses is left to the best judgment of the medical director. (Editor’s note: On page 48242 of the Final FY2014 Payment Rule, CMS provides clarification that while the hospice physician must make determinations about a patient’s diagnoses,“we do not require [the physician] to determine to the actual codes associated with those diagnoses for inclusion on the hospice claim. Hospices have the flexibility to determine how to take the physicians’ information about diagnoses and translate it into the appropriate codes on the claim.”



290.x, Dementia

Code 1st the associated neurological condition. If documentation is Senile or presenile, the appropriate 290 code should be used

  290.0 *

Senile dementia, uncomplicated. CMS indicates this is an inappropriate principal diagnosis for hospice in 2014 Final Wage Index Rule.


Presenile dementia, uncomplicated


Presenile dementia with delirium (acute confusional state)


Presenile dementia with delusional features (paranoid type)


Presenile dementia with depressive features


Senile dementia with delusional features (with paranoid features)


Senile dementia with depressive features


Senile dementia with delirium (with acute confusional state)

 290.4x  Vascular dementia

Also called multi-infarct dementia or arteriosclerotic dementia; Use additional code to identify cerebral atherosclerosis (437.0).  If related to cerebral infarction (late effect stroke), use 438.0 rather than 437.0


Vascular dementia, uncomplicated


Vascular dementia with delirium


Vascular dementia with delusions


Vascular dementia with depressed mood


Alcohol-induced persisting dementia (Alcoholic dementia, Alcoholism associated with dementia)


Drug-induced persisting dementia; use additional code for drug dependence (304.0-304.9) and use additional E code to identify drug.

  294.10 or
  294.11 *
Manifestation Code

Dementia in conditions classified elsewhere.  Code first any underlying physical condition.  See long list of underlying conditions listed below this code such as Alzheimer’s, epilepsy  and other neurological conditions; syphilis, polyarteritis nordosa and other diseases affecting nervous system located in chapters other than diseases of nervous system.

  294.20 or 294.21

Dementia without or with behavioral disturbance

* Dementia codes listed in top 20 hospice principal codes between 2002 and 2012





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