Hospice Claims and Use of Debility, Adult Failure to Thrive, and Dementia Diagnoses

CMS expects that hospices not use ‘debility’ and ‘adult failure to thrive’ as the primary diagnosis on hospice claims effective immediately.
May 10, 2013 08:45 AM

In the April 30, 2013 edition of NAHC Report, a summary was provided for the FY2014 Hospice Wage Index proposal that included some details of the portion of the proposed rule related to multiple diagnoses on hospice claims and specifically hospices’ use of ‘debility’, ‘adult failure to thrive’, and dementia as the principal diagnosis. 

CMS indicated that hospices should not use these diagnoses as the principal diagnosis, and that in the future they will return to provider (RTP) claims with ‘debility’ or ‘adult failure to thrive’ as the principal diagnoses.  In the CMS Open Door Forum (ODF) on May 8, 2013 CMS indicated that instruction to contractors for RTPing these claims would be coming out soon.  No particular date was given but it is clear that CMS has warned providers about the need to RTP claims and that providers should not be coding these diagnoses as the principal diagnosis. 

NAHC strongly recommends that all hospices review each case where ‘debility’ or ‘adult failure to thrive’ is listed as the principal diagnosis.

If those cases clearly have another diagnosis that is considered as a principal diagnosis, the hospice should change this for all future claims.  It is possible that there is not a more specific principal diagnosis and the ICD-9 coding conventions do allow ‘debility’ and ‘adult failure to thrive’ when another more specific diagnosis is not present.  Because of this it is of great concern to hospices that CMS will RTP any claims with ‘debility’ and ‘adult failure to thrive’ in the principal diagnosis field.  However, at this time CMS clearly expects and is strongly communicating to hospices that these diagnoses not be the principal diagnosis.

In addition to adult failure to thrive and debility, CMS also clarified for providers that use of dementia and some other mental, behavioral, and neurodevelopmental disorders as a principal diagnosis is not appropriate.  CMS indicates that the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first, followed by the manifestation. CMS underscores that it expects hospice providers to follow ICD-9-CM coding guidelines and sequencing rules for all diagnoses and pay particular attention to the specified conventions for dementia codes as depending on the code they may or may not be used as principal diagnosis. 

CMS also reiterated in the ODF the expectation that hospices observe longstanding policy of including all diagnoses related to the principal diagnosis on the hospice claim.  This is the third time CMS has made this clarification, and they emphasized how serious they are about this issue. 

CMS also referenced comments made in the 1983 hospice final rule: 

“We are restating what we communicated in the December 16, 1983 final rule regarding what is related versus unrelated to the terminal illness: ...we believe that the unique physical condition of each terminally ill individual makes it necessary for these decisions to be made on a case–by-case basis. It is our general view that ... hospices are required to provide virtually all the care that is needed by terminally ill patients (48 FR 56010 through 56011). Therefore, unless there is clear evidence that a condition is unrelated to the terminal illness, all services would be considered related. It is also the responsibility of the hospice physician to document why a patient’s medical need(s) would be unrelated to the terminal illness.”

A very detailed analysis of the section of the proposed rule, FY2014 Hospice Wage Index Update, related to multiple diagnoses will be distributed soon by NAHC and HAA.

NAHC strongly encourages hospice providers to ensure they are including all related diagnoses on their claims and that they are following all ICD-9-CM coding guidelines and sequencing rules now.   

NAHC is planning further education on these diagnoses and the coding of related diagnoses for the near future.  Please direct questions and comments to Theresa Forster, tmf@nahc.org and Katie Wehri Katie@nahc.org.