1. Requirements Official coding guidelines require the use of V codes for aftercare and specify that applicable aftercare V-codes are to be used for conditions requiring continued / long term care or healing phase of a condition/disease. The official coding guidelines are developed by CMS (Centers for Medicare and Medicaid Services) & NCHS (National Center for Health Statistics) and updated in October and April of every year. http://www.cdc.gov/nchs/data/icd9/icdguide10.pdf

2. Requirements Per ICD-9-CM Official Guidelines for Coding and Reporting, aftercare codes are generally first to explain the specific reason for the encounter (admission) Certain aftercare code categories need a secondary dx code to describe the resolving condition or sequelae For others (V codes) the condition is inherent in code title

3. The FI will not accept V-codes as principal diagnosis - is an INCORRECT statement. The Principal DX must be reported according to Official ICD-9-CM guidelines for coding and reporting, as required by HIPAA including any applicable guidelines regarding the use of V-Codes

4. Not So New Coding clinic Fourth Quarter 1999 Published rules for the use of V codes Addressed the use of V codes in LTC settings Coding clinic Fourth Quarter 2003 Clarified the use of aftercare V codes for all subsequent encounters after the initial treatment for a fracture “for statistical purposes, a facture should only be reported once”

5. CMS Manual System Transmittal 437 Principal Diagnosis Code - SNFs enter the ICD-9-CM code for the principal diagnosis in FL 67. The code must be reported according to Official ICD-9-CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes. The code must be the full ICD-9-CM diagnosis code, including all five digits where applicable. Other Diagnosis Codes Required – The SNF enters the full ICD-9-CM codes for up to eight additional conditions in FLs 68-75. Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-9-CM guidelines.

6. PRINTED IN MAY 05 CHIA Journal © Insights to Coding and Data Quality CMS confirms use of V-codes on UB 92 for SNF billing by Ann G Uniack, RHIA Member, Coding and Data Quality Committee The Center for Medicare and Medicaid Services (CMS) has confirmed that SNFs must use the correct ICD-9-CM codes including V codes on the UB-92 for Medicare billing. Transmittal 437 adds the following to Pub 100-04 Medicare Claims Manual, Chapter 6, Section 30, Billing SNF PPS Services. The CMS online transmittal can be accessed on the Internet at:.http://www.cms.hhs.gov/manuals/pm_trans/R437CP.pdf

7. Medicare Claims Processing Manual 100-04 Chapter 6 - SNF Inpatient Part A Billing and SNF Consolidated Billing http://www.cms.gov/manuals/downloads/clm104c06.pdf

8. 30 - Billing SNF PPS Services (Rev. 2011, Issued: 07-30-10, Effective: 01-01-11, Implementation: 01-03-11) Principal Diagnosis Code - SNFs enter the ICD-CM code for the principal diagnosis in the appropriate form locator. The code must be reported according to Official ICD-CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes. The code must be the full ICD-CM diagnosis code, including all five digits where applicable. Other Diagnosis Codes Required – The SNF enters the full ICD-CM codes for up to eight additional conditions in the appropriate form locator. Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-CM guidelines.

9. So What’s Changed???

10. CVHS implemented of the use of V-codes for principal diagnoses in compliance with official coding guidelines effective October 2009

11. What this means to you The Principal diagnosis can no longer be an acute diagnosis and it may be a V- CODE 800.XX codes for fractures are NO LONGER used

12. What you need to do When sequencing diagnoses upon admission you must keep in mind that acute diagnoses will no longer be part of the diagnosis listing Identify aftercare diagnosis statements and sequence appropriately

13. What if….. Could the facility face claim denials due to this change? NO – the FI is well aware of the ICD-9-CM coding guidelines and requirements.

14. Ready ……..Set…….Go

15. Definition of Principal Diagnosis “ FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admissions to, continued residence in the nursing facility and the diagnosis that support the reimbursement and should be sequenced first.” Medicare – To be covered the extended services must be for the treatment of a condition for which the resident received inpatient hospital services during the 3-day qualifying stay

16. V Codes as principal diagnosis V Codes may be listed as a principal or secondary diagnosis as stated in official coding guidelines V Codes are used in both inpatient and outpatient setting V Codes indicate a reason for an encounter

17. Using V Codes in post –acute care settings When a person is not currently sick encounters the health services for some specific reasons ( e.g. organ donor, inoculations, healthcare screenings, etc. ) When a person with resolving disease or injury, requiring continuous care (e.g. dialysis for renal disease, chemotherapy for malignancy, cast change, etc. ) When circumstances influence a persons’ health status but are not in themselves a current illness or injury

18. Type of Codes used in LTC Aftercare – used when the initial treatment of a disease or injury has been performed and the patients still requires continued care to heal or recover. Late Effects – a late effect is a residual condition that remains and requires medical evaluation, rehab treatments and/or nursing care after the initial illness or injury.

19. Type of Codes………… History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter. A history code is distinct from a “status” code in that history codes indicate that the patient no longer has the condition and “status” codes indicated a present state.

20. What to Code? ALL CONDITIONS THAT EXIST AT THE TIME OF ADMISSION, THAT EFFECT TREATMENT RECEIVED

21. DO NOT CODE DIAGNOSES THAT DO NOT AFFECT TREATMENT OR LENGTH OF STAY WHEN CONDITION NO LONGER EXISTS DO NOT ASSIGN PROCEDURE CODES Examples: Fractured forearm 6 years ago, pneumonia, UTI that were resolved (these will only be coded if the Resident is admitted with Antibiotics)

22. Locating the Principal Diagnosis

23. Section II. Selection of Principal Diagnosis The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” For SNF reason for admission to the facility

24. Admissions/Encounters for Rehabilitation When the purpose for the admission/encounter is rehabilitation, sequence the appropriate V code from category V57, Care involving use of rehabilitation procedures, as the principal/first-listed diagnosis. The code for the condition for which the service is being performed should be reported as an additional diagnosis.

25. V57 – Care Involving Rehab Category V57 does not indicate that rehab services were provided, only that the resident was admitted for this purpose

26. Diagnosis Sequencing The order in which codes are listed is called sequencing. Every effort should be made to record the codes in a logical sequence that is descriptive of the resident’s condition.

27. V-Codes V-codes are assigned to problems that affect the patient’s health but are not in themselves a current illness or injury V-codes can be used to represent status or history. Examples: –Status Cardiac Pacemaker V45.01 –Status heart valve prosthesis V43.3 –History of falls V15.88 –CABG V45.81 Remember not to use acute care codes when coding aftercare

28. Aftercare are used when the initial treatment has been performed but the patient continues to need care during the healing / recovery phase Examples: Aftercare following surgery Physical and/or occupational therapy Aftercare for healing traumatic fracture

29. To “V” or not to “V” Scenario # 1 A resident is admitted for physical therapy following a hip replacement for an inter- trochanteric right hip fracture due to a fall.

30. To ‘V’ or Not to ‘V’: Scenario #1 Physical therapy: V57.1 Physical Therapy Intertrochantic right hip fracture due to a fall: V54.13 Aftercare following traumatic hip fracture Hip replacement: V54.81 Aftercare following joint replacement V43.64 Joint replacement, hip

31. To ‘V’ or Not to ‘V’: Scenario #2 A resident is admitted for P.T. & O.T. following a hip fracture after a fall. The physician indicated that the fracture was due to osteoporosis. The Discharge Summary stated that old compression fractures of the vertebrae due to osteoporosis were present on x-ray.

32. To ‘V’ or Not to ‘V’: Scenario #2 Physical Therapy and Occupational Therapy V57.89 Multiple therapies Hip Fracture (due to osteoporosis) V54.23 Aftercare for continuing treatment of healing pathologic fracture of hip Osteoporosis 733.00 Osteoporosis Compression fractures of vertebrae 733.13 Pathologic fractures of vertebrae

33. Guidelines: the coder should make every effort to record the codes in logical sequence that is descriptive of the patient’s condition

34. Be Patient Once you have sequenced the diagnoses and the MRD is ready to code all of this information can get very confusing and you may be asked for clarification. We appreciate your patience, working together will help ensure compliance with regulatory guidelines as well as maintain the accuracy of our Residents’ medical records