Posts tagged ‘CKD’

November 14, 2011

Jan. 1 M0090 date is the end for case-mix hypertension

CMS has clarified that payment changes relative to the removal of the hypertension codes will be effective with M0090 dates of 1/1/2012.

“Beginning with M0090 dates of January 1, 2012, 401.1 Benign essential hypertension codes and 401.9 Unspecified essential hypertension are removed from the HH PPS case-mix system. Specifically, 401.1 and 401.9 diagnosis codes will no longer result in additional points when computing the HIPPS codes”

Providers should not change the codes they use for hypertension unless they have been coding the 401 codes in error. Changing the codes just to get points is upcoding and we certainly do not want to prove CMS correct about case mix creep. You can be sure that they will be watching for trends in hypertension coding as a result of the case mix change.

Remember hypertension with chronic kidney disease (585) or renal sclerosis (587) changes the hypertension code to the 403 category. There is a presumed relationship between CKD and HTN with HTN causing the CKD.

However, a relationship between heart disease and HTN cannot be presumed. The physician must either state (e.g., heart failure due to hypertension) or imply the relationship (e.g., hypertensive heart disease).

Even if you do not have the information to be able to change the hypertension code to some other category besides 401, do not despair! Remember that hypertension and heart disease are together in Table 4. Even if you do not earn points with the hypertension codes, think how many of your patients with 401 codes also have codes from the 414 category (coronary atherosclerosis and chronic ischemia), 410 (acute myocardial infarction) and 428 (heart failure). Those codes are case mix, too, so you will not be losing any points!

Grouper information!

November 17, 2010

Gangrene and diabetes are a pair, but not necessarily a commitment

My recent diabetes posting has generated a few questions:
Question: Even though diabetes may be the number one cause of a problem or is a major cause of a problem, the only manifestations that can be assumed are gangrene and osteomyelitis. Does that mean that as long as we code DM with circulatory manifestations, the gangrene doesn’t need any other codes?

Question: There used to be an assumed relationship between DM and gangrene. Has that changed?

Lisa says: Gangrene and diabetes are always a fun pair to code! In answer to these questions:

You still need to code the osteomyelitis or the gangrene with your diabetes code. So diabetic gangrene is 250.7x, 785.4. The medical assumption does not mean you skip the manifestation code.

What I meant by “number one cause of a problem or is a major cause of a problem” is that a lot of coders will assume relationships between diabetes and other potential manifestations such as CKD. Just because the patient has diabetes and it is a major cause of CKD does NOT mean that the CKD can be assumed to be diabetic. Besides gangrene and osteomyelitis, other potential manifestations need physician confirmation.

There is an assumed relationship of gangrene and diabetes, that has not changed. What I was trying to explain, and I hope I do a better job of it here, is that while gangrene is an assumed manifestation of diabetes, it does NOT follow that having gangrene means that you have diabetes. Gangrene can be a stand-alone problem, so make sure the patient has diabetic gangrene.