Accurate coding for Alzheimer’s disease is extremely important as it is a frequent diagnosis in home health and may be a primary reason for admission or even complicate care.
To correctly code for Alzheimer’s disease, you must first understand that the term dementia is a general term which describes a continuous decline in thinking, behavioral and social skills and disrupts a person’s ability to function independently.
There are four codes available to assign to Alzheimer’s disease. To code, first begin in the Alphabetical Index with terms “Disease, Alzheimer’s” and note that the default code is G30.9 (Alzheimer’s disease, unspecified).
The italicized brackets next to the code in the Alphabetic Index indicate that it is part of an etiology/manifestation combination, so two codes are necessary in order to code each type of Alzheimer’s disease correctly.
The second code refers to the absence or presence of any behavioral disturbance that the patient exhibits, and further serves to describe the patient’s status. These are captured through codes F02.80 (Dementia in other diseases classified elsewhere without behavioral disturbance) and F02.81 (Dementia in other diseases classified elsewhere with behavioral disturbance).
The manifestation codes for Dementia in diseases classified elsewhere are found in Chapter 5, (Mental, Behavioral, and Neurodevelopmental Disorders) under the category “Dementia in other diseases classified elsewhere.”
All Alzheimer’s disease codes are valid primary diagnosis codes under the Patient-Driven Groupings Model (PDGM), although no comorbidity points are assigned. When coded as a primary diagnosis, it’s important to remember that interventions addressing Alzheimer’s disease and any manifestations should be included in the plan of care.
Tip: An Excludes 1 note in the tabular index instructs us that when coding Alzheimer’s we cannot also code senile brain degeneration or the more general terms, senile dementia or senility.
When responding to M0104 (Date of referral) clinicians should enter the date the agency received a valid referral, and must keep in mind that a primary diagnosis eligible for reimbursement under the Patient-Driven Groupings Model (PDGM) is not necessarily required for a referral to be considered valid.
This is just one piece of guidance included in CMS’ January of OASIS quarterly Q&As published to the CMS website Jan. 21. The latest release of OASIS Q&As delves into issues around PDGM as well as M-items capturing activities of daily living (ADLs) and GG items capturing mobility and self-care.
In the response to Question 3, CMS explains a referral is valid when the agency receives adequate information about the patient including name, address, contact information, diagnosis and/or general home care needs and ensures the referring physician or another physician will provide the plan of care and ongoing orders.
In the scenario outlined in Question 3, the agency receives a complete referral from a physician at an inpatient facility on Jan. 1, 2020, and the patient is discharged to home health that day. The diagnosis provided on the referral doesn’t fall into a PDGM clinical grouping, so intake staff call to get a more specific diagnosis. The agency gets the more specific diagnosis on Jan. 4, 2020 and starts care on Jan. 5, 2020. CMS explains that the agency received adequate information including a relevant diagnosis and had a valid referral on Jan. 1, 2020, so that would be the correct admission date to enter on M0104.
“The assessment process, along with collaboration with the physician, may lead to identification of additional diagnoses for care planning and/or reimbursement purposes,” CMS explains in the response.
Delays in getting care started immediately after receiving and accepting a referral could result in timely initiation of care issues, lapses in patient care, loss of referrals and CMS scrutiny, notes Arlynn Hansell, PT, HCS-D, HCS-H, HCS-O, COS-C, owner of Therapy and More, LLC in Cincinnati.
“You’ve got to get it clarified but get your clinician out there and get that patient started,” Hansell says. “We have a valid referral we just need to get a diagnosis that will play nice in the sand box.”
Absence of a diagnosis code that qualifies for payment doesn’t mean that patient doesn’t need care, Hansell adds.
“We just need a valid diagnosis, so that’s our problem not the patient’s,” Hansell says.
A 69-year-old woman was admitted to the hospital with delirium. Her diagnoses include insulin dependent diabetes and emphysema. She was found wandering in her yard at night wearing her nightgown, and her family reported that she has been forgetting to administer her insulin lately, acting unusually and had lost herself several times while driving in the past few months. She was successfully treated for a UTI but the delirium did not resolve. A geriatric psych workup revealed a diagnosis of rapidly progressing Alzheimer’s disease with associated behaviors. She is having episodes of sundowning at home and SN is addressing her family’s need to learn to manage her Alzheimer’s disease symptoms and diabetes.
Code the scenario:
|Primary and Secondary Diagnoses||Code|
|M1021a: Alzheimer’s disease, unspecified||G30.9|
|M1023b: Dementia in other diseases classified elsewhere with behavioral disturbance||F02.81|
|M1023c: Delirium due to known physiological condition||F05|
|M1023d: Type 2 diabetes mellitus without complications||E11.9|
|M1023e: Emphysema, unspecified||J43.9|
|M1023f: Wandering in diseases classified elsewhere||Z91.83|
Additional diagnoses: Z79.4 (Long term (current) use of insulin), Z87.440 (Personal history of urinary (tract) infections).
- The focus is on the family learning to care for the patient’s rapidly progressing Alzheimer’s, therefore you would first code G30.9 (Alzheimer’s disease, unspecified).
- The provider has identified behaviors, including wandering, so you would follow that code with F02.81 (Dementia in other diseases classified elsewhere with behavioral disturbance).
- Delirium episodes are continuing and would be captured with F05 (Delirium due to known physiological condition).
- The comorbid diagnosis of diabetes with insulin administration is a focus of concern for the family. This would be coded through assigning E11.9 (Type 2 diabetes mellitus without complications)
- The patient’s emphysema would be captured through coding J43.9 (Emphysema, unspecified).
- The documentation states the patient has been found wandering. This would need to be coded through assigning Z91.83 (Wandering in diseases classified elsewhere). Note: Per a “Code first” note listed under Z91.83, you must first assign the Alzheimer’s code before assigning this code.
- Additional diagnosis codes Z79.4 (Long term (current) use of insulin) and Z87.440 (Personal history of urinary (tract) infections) would be assigned in this scenario.