Watch the recorded webinar below…

Transcript

0:02 Everyone, and welcome to Roundtable 156, Navigating Codes for Dementia and Related Conditions. So, with us today is Janice …, Director of Advanced Education for … Division. My name is Scott … and the Vice President of Auditing Encoding Education, here at Saks Health.
0:22 Some housekeeping real quick, first, there’s no column numbers format is streaming only, the streaming only format allows us to accommodate large numbers of attendees. So that’s the reason for that. Today’s webinar will be available on demand after the live session and will be accessible through a link that will be that will provide in our follow-up e-mail, which will be sent out this afternoon.
0:46 Please make sure that you are opted into our e-mails. That e-mail will come from Coding Roundtable’s, it’s XML dot com.
0:53 Please make sure we are in your Safe senders list and not being routed to junk or otherwise blocked. The e-mail will contain a link to our CEO landing page. Right now, there’s the CU from the last webinar, still up there. So, if you haven’t grabbed that yet, go ahead and grab that before it’s replaced.
1:11 You have two weeks from today’s date to download your CEU. We cannot issue CEUs after that point. During the webinar, you can download the handouts. Alright, So I saw that Janice had that available already. Be sure to visit the Sax Health Webinar resources page for updated roundtable information. And we should have a roundtable scheduled for quarter 2, 2023 up there in the next few days.
1:33 We’re just putting some finishing touches on that, um, quick survey at the end of today’s webinar and really appreciate if you took your time to complete that.
1:44 So, that’s it, Janice. It’s all yours.
1:47 All right. Thanks, Scott.
1:50 Smooth along here. Um, so, as Scott mentioned, we’re going to be talking about navigating codes for dementia and related conditions. So, kind of a bit of an agenda just before we get started.
2:04 Know, we’re going to talk about why the changes were made, kind of give some background, It’s important to me, it’s important to understand why codes were created, what the purpose is, It kind of gives you a better idea of how to assign the codes, where they’re coming from.
2:20 I just think it’s, it’s interesting as well, very. We’re going to talk about changes to the code set regarding our fiscal 2023, and I’m sure we’ve all heard about the changes, but I want to specifically look at the Tabular an Index. Because I think that’s where we, we’ve been seeing some coding, challenges, errors, things like that. Documentation, improvement, opportunities. And then, I’ll talk about the guideline update. If you haven’t heard about that, or notice that yet, if you’ve been on a webinar with me, you’ve probably already heard about it. And then at the end, if we have time, I do want to spend, I do want to allow some time to discuss specific challenges that maybe you’re having at your facility or organization. And kind of stop there, and take note of those things.
3:08 So, that maybe other facilities have have had a solution to those challenges. And maybe you want to share that with, with the group. We do have the question box that we use for discussion points, if you want to add your, your comments there.
3:26 So, that’s kind of the agenda for today. But you can use the question box. It’s, I apologize this format. Or, this doesn’t allow you to see every single comment. I don’t have the ability to make them public, so, I’ll read them off and then we can discuss those as we go along.
3:43 Um, so, um, just to mention there is a hemo CEUs that Scott mentioned regarding this presentation. There’s also a slide at the end if you download the handouts regarding information in regards to CU, if you missed the introduction by Scott.
4:07 Um, so please download the handouts, check out the last slide, you’ll see more information about that.
4:16 Alright. So, let’s talk about background In fiscal 2020, or fiscal year 20 23, October 1, 2022, they introduced over 69 new dementia codes along the new access of classification.
4:32 So, if we think about how they expanded those codes, which we’re going to talk about, that created 69 new codes within our dementia category.
4:43 Of course, are optimizing dementia documentation. Before we just had our dementia with behavioral disturbances, it wasn’t clearly in my opinion, You know, what is a behavioral disturbance, so they’ve expanded those codes and, you know, they can have some improvement and CC capture with the expansion of the codes, and we’re going to talk about that.
5:07 So, let’s get going here.
5:14 OK, so, Dementia, Before we actually get into the coach structure that takes into account the stage of severity.
5:24 and behavioral and psychological symptoms.
5:29 Um, we have to consider the different types of dementia as well, but we know that Dementia is also known as a major neurocognitive disorder. There was before they added these terms to the index.
5:48 It was a little bit unclear where we would code major neurocognitive disorder and mild neurocognitive disorder. So they’ve changed, kind of added some terminology there, that major neurocognitive disorder at least the last couple of your years ago, before they made the changes and added those terms to the index and the Tabular. But major neurocognitive disorder is classified to meant to dementia.
6:11 We’ll talk more about mild cognitive impairment, which is, is not can it to where it hasn’t progressed to dementia at that point? So, it is characterized by significant decline in cognitive function. As we all know, memory, problem solving, attention, language skills and we we think about general underlying disorders such as junk cerebrovascular disease, Alzheimer’s disease. Of course, we have many different specific underlying disorders. And sometimes the disorder that’s causing the dementia can’t be identified, right. We have an unspecified dementia code as well. They don’t always know the underlying cause, but there’s a ton of different causes of dementia, and we’ll talk about some of those as we go through the slides.
6:59 The reason they wanted to expand these codes, this is from the co-ordination of maintenance meeting. I put this the links to the references at the end of the slide, if you want to have the reference.
7:11 It includes all the codes are a lot of the codes that they discussed are created over the last year or two, when also codes that, probably will be coming out in the future, but there’s a lot of great information in those slides. I mean, if you actually listen to the maintenance meetings, they actually discuss about more, they go into detail about the intent, and you can actually ask questions during the call. If something isn’t making sense, and they actually take the advice of the people participating, and kind of maybe add excludes one nodes or excludes two nodes, if something doesn’t make sense of revise a guideline, they take those, though, the commentary into account.
7:49 Those are, those calls are actually quite interesting, and you kind of get some more insight into how to use the codes that may not be necessarily on, in, that, in those, those documents that they supply.
8:04 They do follow it usually follow up with a question and answer sheet that answers a lot of the questions as well after the presentation is over.
8:12 So, anyway, kind of off off on a tangent there, but, again, I think it’s interesting learning about codes and how they’re created, and stuff like that, Anyway. So, we have our chronic condition. Dementia is a chronic condition, and the impact on health care is tremendous when it comes to dementia.
8:32 They want to better be able to better track this.
8:37 You know, as the stage of dementia goes up, the the impact it has on the healthcare system. So, we all know that the pass codes for dementia didn’t identify the stage of severity. So, for those on the call, Have you been seeing the stage of dementia being documented in the record? Is it something that’s a priority for your, maybe, your clinical documentation improvement, or just maybe before, we just didn’t notice that, the documentation for the severity, because it wasn’t something that we captured on the code assignment. Let me know in the comments.
9:11 Um, section, what you’re kind of seeing in the documentation, so they didn’t fully describe it. Also, the old codes didn’t fully describe the behavioral and psychological symptoms of dementia.
9:24 And of course, we all know, depending on their behavioral and psychological symptoms, the clinical elements are major factors and management of patients, right? Are they in assisted living or are they in a SNF?
9:40 Are they on this medication or that medication? Are they on in restraints?
9:45 Um, you know, the level of care kind of varies based on the level of dementia and also their behavioral and psychological symptoms, right? So.
9:57 Dementia is progressive.
9:59 There’s a long term, a need to kind of a longitudinal longitudinal need to capture data, to see how patients progress, and over time for research and clinical studies. So that’s one of the main, main reasons they want it to create. Of course, you don’t notice, and you don’t see them mentioning anything about reimbursement here, but it does really impact reimbursement.
10:23 The severity of illness of the patient over time, know, the cost of care becomes a burden from that aspect.
10:33 So just in general, dementia is a decline in cognitive function that impairs the ability to perform activities of daily living so it may involve any cognitive issues. Memory is the most common.
10:46 We also have common neurodegenerative Stewart neurodegenerative conditions are the cause? Sometimes these are reversible.
10:55 However, it’s taking talking about mild cognitive impairment impairment it is net, not necessarily something that leads to problems with daily activities of daily living, but these patients will progress eventually to dementia. So they want it’s kinda like the first sign of an issue, but the patient doesn’t yet have dementia. So they want to also track that over time, as well. They do have some stats. Let me go to the next slide.
11:26 She has it in my comments.
11:34 Yes.
11:36 I thought I had some stats here, but maybe I took them out. I don’t remember what they are, or maybe it’s on another another slide. So, stage of severity. We have the progression of dementia moves through characteristic stages of cognitive impairment or neuro behavioral changes. So we have mild, moderate, and severe.
12:00 In accordance with the definitions there is a broad consensus: consensus. These are stages routinely used by clinicians working with dementia patients, including the American Academy of Neurology, The American Geriatric, Jerry Jerry Action, Geriatric Society, Jarrah, Topological, Society, The National Society of Aging and the Alzheimer’s Association. So, one of the questions, and I think we’ve talked about this before.
12:28 As I have some, sometimes, this question came up before and another another, another webinar, but, we have mild dementia. I’ll get to that in a second.
12:37 Moderate dementia and severe dementia, So, does advanced dementia equal severe dementia?
12:44 Just, I’m going to throw that out there. If anyone wants to comment on that. Does advanced dementia equals severe dementia?
12:53 Um, so, just some of the comments. So far, we rarely are seeing the stage of severity.
12:59 We see it says, advancing it, but it doesn’t say from what to what.
13:07 Severity of dementia doesn’t appear to be a focus for documentation CDI, Just reading some of the comments?
13:14 I have seen some mild dementia being documented and some advanced dementia being documented.
13:22 Then, another comment stages have not been used that much at our facility yet. I think it’s important that it it may become an important factor, right, for unspecified, you know, without behavioral disturbance. Maybe, in the future, they do make severe dementia without behavioral disturb. Determine behavioral disturbances.
13:46 A, C, C, And just make those other code, you know, the the other codes, not SEC, right now, all of the Codes, whether they’re mild, moderate, severe unspecified, with behavioral disturbances, are all, you know, acting as a CC, and that’s probably one of the reasons. It’s not such a focus for CDI. Or, you know, there’s a lot of other things that we need to worry about.
14:08 I was just curious if that was something that your facility was focusing on.
14:15 Right now, it may not be it’s not as much of an impact on reimbursement.
14:19 But again, you know, they they do look at the CC list, the MCC list and we’ll make changes to those over the course of the year based on data.
14:28 So, We’ll see what happens with that.
14:34 It should be noted that, or I should, I guess I should go over the definition, sorry, mild dementia, it clearly, it clearly has functional impact on daily life affecting mainly instrumental activities.
14:45 The patient is no longer, fully independent, requires occasional assistant with daily life activities, moderate extensive functional impact on daily life with impairment on basic activities, no longer independent and requires frequent assistant with daily life activities. And then, severe dementia clinical interview may not be possible. Complete dependency, just severe functional impact on daily life. That’s impairment in basic activities, including basic self care.
15:11 So, you can here, see, there, are, you know, the advancement of from mild to severe.
15:19 We do, it should be noted that a diagnosis of mild cognitive disorder, also known as mild cognitive impairment, has been recognized as preceding dimension, I mentioned that on the left side.
15:29 Um.
15:33 The pre dementia states also known as pre dementia. It may be protracted, but it may also progress to dementia, so they want to track that as well.
15:43 Um, management in the earlier stages consists of establishing coping behaviors and managing symptoms with medications.
15:51 Other medications are introduced in later stages, when symptoms and associated conditions are more severe, a new environment, or contract caretakers often become necessary, and then research suggests that health care costs increase increase as the stage of severity does. So that’s, They want to prove that.
16:08 I’m not sure how they’re going to prove that if we don’t capture the, the specificity in the dementia.
16:15 So, I do see that as being problematic if they’re using our coded data.
16:21 And I think that’s the purpose of the coded data, is to provide some research data, so that they can look at the data and say, OK, this patient who has severe dementia is costing more than someone with mild dementia. So, you can see that impact, you know, if we’re not capturing it.
16:38 So, I want to make a note here that, over the last few months, over the last few months, met the main issue, I saw with dementia codes have been, in a couple of cases, it hasn’t been a lot of cases, a handful of cases where the stage was actually documented.
16:59 Um, so, Maya, a lot of cases, it was documented as mild.
17:05 It was actually documented as mild dementia.
17:08 And decoder just code and you know, unspecified severity. So, there, I think there is a little bit of opportunity to look for the stage. The stages. There may be some query opportunities.
17:20 Of course, we have a ton of queries that we need to already submit, but, if we see if the patient is completely dependent on, you know, self care, that may be an opportunity for queries, for maybe severe dementia, for example.
17:38 Millimeter, OK, taught whoops, Me Move on to the next section, which is behavioral and Psycho physiological Symptoms of Dementia. So, before we just had one code right with behavioral disturbances, what did that mean? You know, it was kind of hard to to kind of describe or assign that code. Usually we’re looking for behavioral disturbances in the documentation. So, now that we’ve, we’ve had, we’ve had no expansion, we have a little bit more detail about what makes up a behavioral and psychological symptoms of dementia.
18:18 And they abbreviate that as The, D S D S, behavioral and psychological symptoms of dementia, within this document that’s available for us.
18:29 So, they’ve added other associated disorders, so psychotic disorders, mood disorders, anxiety within the behavioral disorders.
18:40 They want to specifically distinctly identify agitation.
18:46 So, they’ve kind of combined these behavioral psychological symptoms and non cognitive behavioral changes within these codes so, we have our behavioral disturbances. So, the structure I should say, the structure, has been broadened to include behavioral psychotic and mood affective disorders.
19:09 This will also support the national partnership to improve dementia care, and that is a CMS priority.
19:15 And, again, if we’re not using the codes or getting that specificity, I do foresee, though, them probably make, you know, changing some of those to non C Cs to because, what’s the point of doing this. If no one’s going to use that specificity again, I’m just talking out loud here.
19:37 And, you know, the reason for our COTA data, again, just mentioning that anxiety is also common behavioral and psychological symptom of dementia. So they’ve added that.
19:53 ICD 10 classifies anxiety separately the literature does mentioned that sometimes our affective disorders do include anxiety, but the classification does CP and classify them separately.
20:07 And then patients may have more than one of these, right?
20:12 In listening to the maintenance meeting, they did say this is not a hierarchy, where you only can assign one code.
20:19 If a patient has more than one of these, if they have anxiety, and they have some other behavioral or psych psychological symptom and another code category, you can code multiple codes from that code category. Was the intent of these codes.
20:36 So you may have more than one code assigned based on the different types of behavior or psychological symptoms of dementia.
20:48 Yes.
20:51 So the key as Seuss associated disorders that represents a significant clinical problems in their own right are actually responsible for driving the care provided to dementia patients.
21:02 So these disorders are typically what brings patients to the attention of clinicians.
21:08 So if someone is having agitation, that’s alarming, Right? So that usually prompts an emergency department visit.
21:16 Um, a lot of times the dementia itself, the underlying cause of the dementia, is not directly treat it. Usually it’s managing the associated behavioral disorder. So dementia with delusions and hallucinations may result in psychosocial interventions or anti-psychotic medications. So we have to keep that in mind.
21:38 also, when we’re looking at the treatment of dementia, as we’re, you know, just this patient actually have dementia, What exactly are we looking for?
21:48 So, they want, again, another reason they want to start tracking these disorders for patient outcomes, quality of life, cost of care, accelerated mortality, et cetera, then the agitation. That’s usually when you see patients, you know, the disruptive behavioral associated with …
22:09 institutionalization, so, you know, patients being, you, know, please send a nursing home.
22:18 And, also, some of the studies do, indicate that the correlation between psychosis and acceleration of cognitive decline, and increased mortality, and increased mortality.
22:28 So, as as those go up, the mortality goes up as well.
22:41 OK, and here’s just the, the Coding Clinic. We’ve already discussed most of this information. We have.
22:48 So, the categories that were created, we talked about the severity, the severity and the behavioral and physical symptoms of dementia, they were applied to vascular dementia, dementia and other diseases classified elsewhere, and if you think about dementia and other classifies diseases, it’s classified elsewhere, that kind of takes into account. A large number of, of the dementia codes will take a look at the codebook and look at that.
23:14 Then, unspecified Dementia.
23:17 So, they talk about the major neurocognitive disorder, we already talked about that.
23:22 Then, we have the progression of dementia.
23:24 They talk about, you know, they’ve added mild, moderate, severe, and how, you know, Mild Dementia may, not, patients may no longer be fully independent, and as we progress up to severe dementia, that they need full.
23:38 There are severe, severe, functional impact with impairments on basic activities, including, basic care, um, and then, also, taking into account our physical symptoms.
23:50 Also, just to kind of sum up, this is everything that we’ve talked about.
23:58 Know, as we put, you know, physical symptoms, it’s kind of what tends to why patients tend to present for care. Right.
24:06 one of the question, the question that they did ask, Are they included in this Coding Clinic was a patient with known severe dementia due to late onset Alzheimer’s disease and functional quadriplegia submitted from a Senior Living Facility due to increased agitation and combativeness over the past three days. What is the appropriate code assignment? So, we can code G 30.1 for Alzheimer’s with late onset. I don’t know about you, but I’ve never, I hardly ever see late onset early onset once in awhile You’ll see it. But, you hardly ever see that documentation in my experience, but, anyway, and then F 0 to 2, C, 1, 1 dimension.
24:41 other diseases classified elsewhere severe with agitation.
24:47 And then the functional quadriplegia can also be assigned.
24:51 Yeah.
24:53 OK, so there’s some people asking questions about we’re gonna get to that assigning you know, if they have, If they have anxiety with dementia, we’re gonna get to that in just a second. So if you, when we get to the index, we’ll talk about that.
25:09 That’s kind of one of the main reasons we’re having this call today.
25:12 So we’re gonna get there, just kind of doing the background and talking about that, just so we kind of have a basic understanding of kind of what we’re looking at. So, we also have to talk about mild cognitive disorders due to known physiological conditions. So they might not actually have dementia, but have this mild cognitive disorder.
25:32 Just keep in mind, if they say mild cognitive disorder, and they have dementia, you kinda have to look at the rest of the documentation, because typically, someone that has mild cognitive disorder hasn’t yet progressed to dementia per the definitions.
25:49 So you may have to no query, et cetera. I think there’s an excludes note there for mild cognitive disorder, but I actually did find an error in the codebook that probably needs to be fixed. We’ll talk about that when we get there.
26:06 But anyway, so we have just, Oh, here’s some of the stats that I was talking about. The American Academy of Neurology noted the patient’s progress dementia at a rate of 12% per year, and when followed up in six years, approximately 80% of them will have convert it to dementia.
26:22 So one of the reasons they want to track this, and it’s actually been increasing over the years, I don’t know, maybe it’s juda better identifying these patients, but they want to, they do want to track this because they, the hope is that clinical interventions might slow down the progression of the disease or whatever the underlying illnesses. And I know dementia affects a lot of us and our families.
26:47 So, I mean, I personally think that the data is important to everyone, I mean, dementia is, is not, is not a fun thing to deal with when it affects sure family member.
27:02 So they want that. That’s another reason they want to track mild cognitive disorder or dementia.
27:11 Because there the hope is to prevent it from from progressing to full on dementia or even severe dementia.
27:22 And there’s a lot of interest in clinical. You know, clinical research and interests. Especially with Alzheimer’s disease.
27:32 The other ones that they’re looking at is Frontotemporal degeneration. HIV related dementia, Lewy body disease traumatic brain injuries, we see a lot of stuff with traumatic brain injuries, right? Parkinson’s disease and Huntington’s disease.
27:47 And then we may see those in those categories where it hasn’t yet progressed to dementia. So they did add that mild cognitive disorder.
27:59 OK, so just a comment, someone made, I get more the late early onset than I do the dementia stages, OK?
28:09 That might be true. Yeah, you don’t really get the stages, and here’s just a Coding Clinic. We already talked about that. So it’s just here for a reference.
28:17 So the one thing I do want to talk about is that sometimes when a patient comes in, maybe they’re having some behavioral disturbances. Maybe they’re having delirium. Maybe they’re having encephalopathy. They’re always going to exclude reversible etiologies. Maybe the patient doesn’t have a history of dementia.
28:37 So we may see work ups for other, they always want to exclude reversible etiologies, right?
28:44 When they’re doing a dementia workup or delirium workup, um, know, sometimes our infectious metabolic neo plastic, autoimmune, can mimic the progressive cognitive decline and dementia And sometimes those can be reversible right? Like we think about where nicki’s encephalopathy, which we classically see that with.
29:04 We see that with alcohol abuse or dependence, right?
29:09 It’s called caused by a thigh immune deficiency, an interesting way.
29:12 I just was reading a case where the patient had, um, the patient had actually an eating disorder, and they had severe … deficiency. And they actually had this, So that was an interesting case. So it’s not just alcoholics.
29:30 It can be also seen in vitamin deficiency of deficient states, so you can see this with maybe someone that has an eating disorder, maybe someone that status post, a gastric bypass, and they can’t absorb vitamins.
29:43 Know, they may present with confusion a tax year. And basically, the treatment is going to be IV Thiamine, right? I know I’ve seen that, that recently. It was an interesting case. They didn’t actually have dementia. The patient was quite young anyway, but that was an etiology or something of exclusion. They still want to do that with older patients as well, right? Someone that’s, you know, in their thirties and forties are probably not going to automatically think dementia. So they’re gonna exclude that pretty quickly.
30:15 But they still want, they still want they should still be excluding these reversible etiologies when they’re working up, someone for dementia. We also have delirium and, you know, looking into doing some research. You think that it’s easy to distinguish you know in the documentation we see a lot of you know back and forth delirium, dementia, encephalopathy, you know different terms being thrown around.
30:40 Maybe it’s dementia, it’s really dementia, it’s not or maybe it’s no delirium or dementia with delirium. You know, looking at some of the information that I was able to look at online, looking at, like consensus information. They basically said it’s not really easy, it’s not an easy distinction but they do want to rule out reversible, etiology. So if the patient is getting better, you know, for treatment, you know, by discharging a drug or treating an infection, that can be probably acute delirium on dementia, for example.
31:18 You know, is the is the change in mental status acute onset from hours to days or has just been more of a chronic issue or maybe it’s a chronic issue with acute worsening.
31:28 Um, so, those are some things that we also want to keep in mind when we’re coding our dementia cases.
31:37 But again, the distinction is not easy. I’m sure we have a lot of queries on our change in mental status cases.
31:45 If it’s not 100% clear, Then sometimes even their dementia or dementia patients may present with symptoms that resemble delirium but it’s really, you know, maybe the patient hasn’t been around people, they haven’t seen that around people. They haven’t seen that decline over, you know, long period of time.
32:09 And then, of course, you know, we have drug use, drugs, maybe it’s an adverse effect. We have met about other metabolic disturbances, you know, maybe they have a Rino issue, liver failure. Is it truly, you know, an acute metabolic issue? Or is it a long term, you know, chronic dementia? Just something that we asked, we should be keeping in mind as well. I mean, from a provider perspective they are doing some exclusion here to make sure that it’s a reversible. Is it reversible or not?
32:43 Ooops, So let’s move on to the actual coding of these conditions taking a look at the Tabular an index.
32:50 So first up this is going to answer some of your questions, OK. So sample index this is for unspecified dementia.
32:59 Our first line is dementia preexisting unspecified without behavioral disturbance psychotic, disturbance, mood disturbance, and anxiety.
33:08 And what does that width indicate to us?
33:17 This should answer your question. For those that.
33:21 for those that are asking the question about, if someone has dementia and anxiety, what does that width indicate to us in the index?
33:41 Anybody?
33:46 OK good, so there’s an issue, because of the width: skyline.
33:50 There’s an assumed relationship, right.
33:53 So, unless they tell us it’s due to something else, there’s an assumed relation.
33:58 So, if so, if we if we have unspecified dementia, and they have agitation, because of the width guideline, we’re going to assume the agitation is related to the dementia because of the width guideline.
34:10 If they have anxiety and they have dementia, because of the width guideline, we’re going to assume the relationship unless another causes stated. Of course, we can break the link if they tell us if they tell us that it’s due to something else.
34:24 Right, so if they’re, they’re in a delusional state and they have dementia, we’re gonna code dementia with psychotic disturbance.
34:32 If they have aggression and they have dementia because of the width guideline, we’re gonna assume that there’s a relate the relationship is there and we’re going to code dementia with verbal or physical behaviors.
34:46 So, good. So I think you guys answered your own question, right? Assume a causal relationship, thank you, Kevin Enlists documentation states otherwise.
34:55 Right.
34:55 So we’re gonna assume that relationship here because of the width guideline. Let’s take a look at the width guideline.
35:03 So the word with her in don’t forget about N right anemia in chronic kidney disease is an example the word with, so diverticulosis with bleeding, hypertension, with CHF, know. These are all different examples. unless they state that they’re due to another cause, we’re going to assume assume the relationship. So the word with or in should be interpreted to mean associated with. or due to when it appears in a code title the alphabetical index, either under main term or sub term, or an instructional note in the tabular list.
35:36 The classification presumes the causal relationship between two conditions linked by the terms in the Alphabetic Index or Tabular.
35:44 These conditions should be coded as relieve it related, even in the absence of provider documentation, explicitly linking them unless the documentation. So this is the part that coders forget, unless the documentation clearly states that conditions are unrelated. So when we do, they do state they’re unrelated.
36:00 Then we can break, break the with link, or break. I call it breaking the link.
36:06 So we don’t want to forget that. If they do say, it’s another cause due to something else, Then we can break that link.
36:15 Of course, we have other guidelines that requires a documented linkage. Specifically, like sepsis, you can go to sepsis with organ dysfunction. But the sepsis guidelines specifically states that the organ dysfunction has to be associated with sepsis in order for us to code that. So, don’t forget to check out your guidelines as well. For those, those as well, I think sepsis. I forget what the other one. The other one I can think of, is, like the substance use.
36:44 We have that, know, that documentation that says, we need to have them state that it’s related. But anyway, for conditions not specifically linked by those relationship relation, relational terms in the classification, or when a guideline requires that linkage between two conditions explicitly documented, provider documentation must link the conditions in order to decode them as related. So when we have the width, then we can assume the relationship. And that’s the case, right? When we take a look here, we have a width.
37:15 No anxiety.
37:16 Just behavioral disturbances, mood disturbance, et cetera.
37:24 Hopefully, you guys can see this, I, when I was looking at it, it looked big enough on my screen.
37:28 You could probably always zoom in on your screen if if not we see under … or open up your Codebook, whatever, it’s big enough on my side so hopefully it’s big enough on your end. First up, we have unspecified dementia, we’re looking at the Tabular. We see that we can see that major neurocognitive disorder sometimes I have come across just major neurocognitive disorder, not otherwise specified documented. That’s included in our S O three code: unspecified dementia.
37:59 Priest Senile dementia, primary degenerative dementia Senile dementia Senile dementia depressed or paranoid type senile psychosis and O S. Then we have our excludes one so if they have sent out since senility we that’s excluded from our Dementia code. And then we have an excuse to note. So I want to talk. I wasn’t meaning to talk about excludes two notes specifically. But I’ve seen a lot of errors lately with excludes two notes. What’s the difference between an excludes OneNote and excludes to know?
38:34 Yes.
38:43 I’m not sure what the comment means. Index Trump C C.
38:48 I wasn’t talking about FCC, so I’m not sure what you’re referring to unless you wrote another comment somewhere, and I just didn’t see it.
39:05 Um.
39:16 OK, you wrote another comment. That’s a whole nother, another issue there.
39:26 OK, so I think we need to talk about, I see, I think we’re confusing that the difference between excludes two notes and excludes one notes Some people were saying that it means never coded excludes two means never coded here.
39:39 So let’s take let’s bring up the guidelines and take a look, take a look at what the excludes note excludes to note means.
39:50 Do I have my CM guidelines up I have to actually bring up my sim guidelines mmm hmm.
40:07 Um, let me get those same guidelines up.
40:18 Yes, some of you are getting it right, but there’s other.
40:20 There’s some people that are flipping those, So let’s talk about it.
40:38 I have been seeing a lot of, I have been seeing a lot of coding changes based on interpreting excludes two notes, So, I think that’s a good time to talk about it.
40:55 Of course, I had PCS guidelines up, but not CM guidelines.
41:02 OK, there we go, hmm.
41:13 All right, Come on, Let me move this over. I’m trying to move it over to the other screen here.
41:18 There we go.
41:21 Yes.
41:36 OK, excludes notes.
41:40 Hopefully everyone can see that.
41:42 Make it bigger.
41:45 Actually that’s too big because Senate.
41:51 OK, Exclude one A Type one excludes No is a pure excludes No it means not coded here. And excludes one no indicates that the code exclude, it should never be used at the same time as the code above the excludes OneNote.
42:06 Excludes OneNote is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Of course we have an exception to the excludes OneNote.
42:17 An exception to the excludes one definition is the circumstances when the two code conditions are unrelated to each other. If it’s not clear, what are the two conditions involving excludes one no or unrelated work inquiry the provider? So, for example, we have code F 45 8 other somatic form disorders, that has an excludes OneNote for sleep related teeth grinding. Because Teeth Grinding is an exclusion term for F 45 8, only one of the two code should be assigned. However, Psychogenic dysmenorrhea is also an inclusion term under F 45 8, and the patient could have both this condition and asleep related teeth grinding. So in these kids, this case, it’s clearly unrelated to each other. So you can go ahead encode both.
42:57 Next excludes two notes is a type of excludes note that represents not included here.
43:03 Excludes to know indicates the condition excluded is not part of the condition, represented by the code, but a patient may have both conditions. When excludes do you know? Appears under a Code Title? Is it except it is acceptable to code both the Code and the excluded code together when appropriate, so it’s not included in the Code assignment of the other Code?
43:24 OK, so I just wanna make that clear. And to keep that in mind, as you’re you’re coding, when you’re checking your excludes, 1 excludes 2 notes that you’re paying attention: we can’t code something with an excluded. Excludes OneNote. Excludes two means that we can code it as an additional code.
43:44 A good example. I don’t have my book up right now, I don’t think maybe I do is, they change the guideline, and I think I do have my book up for our long term use of insulin right.
43:55 Um, where we can encode the insulin, the hypo out R Z 79 for. Let me go to that.
44:11 So we have used an additional code, but if we go that, in there, also, on an hypoglycemic. It’s gonna say excludes, too.
44:18 Let me go to the Z codes.
44:28 We have an excludes to long term use of anti injectable, non insulin it, diabetic drug, so we can encode that in addition to our insulin. It also excludes oral height anti diabetic drugs so we can also code if they’re on oral anti diabetic drugs, such as for an example, right? To show how to interpret our excludes two notes. so back to our presentation, we see there’s an excludes to note for unspecified dementia. If they have dementia with delirium or acute confusion of state, we can also code the S O five code.
45:02 So delirium due to a different an underlying cause. We can encode that as an additional code.
45:07 Because there’s an excludes to note here that’s not included in our F O three code.
45:16 OK!
45:18 then we have all of our code you can see I can’t put every single possible code. on the screen it will take up way too many slides. So I just put a sample sampling kind of show the classification and how is expanded. So we have our unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance and anxiety so dementia OS.
45:40 Now, this code is not a C C, but anything else with behavioral disturbance so F 03911, unspecified, savary severity with agitation, all the way through two are severe, unspecified, dementia severe with behavioral disturbances. Any any one of these codes with a behavioral disturbance?
46:03 Or psychotic, disturbance or mood disturbance or anxiety will be classified as a C C?
46:10 So, it’s important that we’re capturing that.
46:14 And you can see they also include other inclusion terms under these. So, I would be checking these out if you have someone that has restlessness rocking pacing, exit seeking.
46:27 No, that would be included in R S R.
46:31 Are agitation with Agitation.
46:35 If they have other behavioral disturbances, so if they have sleep disturbance, sexual dis, inhibit inhibition, social dis inhibition, that would be under our other behavioral disturbances and then we can also code the wandering. And this is applied across all of these new codes.
46:54 And, as I mentioned before, we can have, let’s say, mild dementia with anxiety.
47:01 Maybe we code unspecified, dementia mild with anxiety. And we also have someone that has agitation. So you can you, as you can see, there’s no excludes No, you can’t. It doesn’t say you can’t code …
47:13 A 1 1 with FO three, A four.
47:17 These are different manifestations of dementia.
47:20 So, you might possibly have more than one code coded for your dementia patient depending on what their manifestations are.
47:33 OK, OK, so here’s our sample index, moving on to vascular dementia. I do want to talk about an issue that I’ve been seeing, and some of you on the call may have been involved in these conversations. But Vasco, Jim and let me know. What other issue are you having any issues with vascular dementia and sequencing, if that’s why they’re coming in?
47:55 Maybe it’s a psych chart.
47:56 Maybe they’re coming in for no agitation or something like that. It ends up they have vascular dementia. So we have vascular dementia.
48:06 Of course, it goes to F 0 1 5 Oh, without behavioral disturbance, but again, we have our widths.
48:13 So with anxiety, you know, if it’s mild with anxiety, we’re gonna go to the specific severity, if documented behavioral disturbances, et cetera. Make sure you’re checking your inclusion terms there.
48:26 So, we have mild again, with anxiety F 0 1, A four. If they also have behavioral disturbance, we can also code the F 01818. But let’s take a look at the Tabular. So vascular dementia includes, as a result of infarction of the brain, due to vascular disease including hypertensive cerebrovascular disease, includes atherosclerotic dementia, major cognitive disorder due to vascular disease and multi infarct dementia.
48:55 So the problem that I’m having or seeing is this code first note the underlying physiological condition or sequela of cerebrovascular disease is any does anyone have has has anyone have any problematic issues with vascular dementia and sequencing?
49:28 OK, so I’m seeing that.
49:29 Yes, you are having some issues and what are the issues? If you could let me know. So we’ll get to that in the next slide, but let’s talk about the other codes that we have here.
49:43 So vascular dementia We talked about including atherosclerotic dementia, may multi infarct dementia, but what are we going to use as the Code first condition?
49:54 So the issue that I have been seeing is that the doctor or provider is not documenting the underlying condition.
50:02 So is it due to a sequela of a previous stroke? Is it due to atherosclerosis, et cetera?
50:10 Then when you query, the doctor says, I don’t know.
50:15 Well, how do you not know if it’s a vascular If you’re call it you’re diagnosing the patient with vascular dementia there has to be a reason why you think it’s vascular dementia right.
50:24 Whether it’s something on the cat scan or the MRI. So I think it’s also the way we phrase, I don’t think they know what we’re asking.
50:34 So one of the things I’m suggesting or this is going to be is to include the things that are part of a possible … a possible option for them to choose from right? If we look at actually, let me go to.
50:51 the options in our Tabular, these are just some of the … and some of the options under cerebrovascular disease is This is an all inclusive I Just pick this section. We have dissection. We have cerebral aneurism We have cerebral atherosclerosis. Most times, we’re probably going to be using cerebral atherosclerosis. We have Luca and Sephora, Vascular lugo encephalopathy.
51:13 That might be an option Maurya Moya disease: chronic ischemic ischemia, cerebral ischemia.
51:22 So we have acute which is probably not going to be acute. It’s a Dementia is a chronic condition, right? We have chronic cerebral ischemia as an option. We have hereditary cerebrovascular disease. I mean, these are these are going to be pretty obvious if that’s what it’s due to.
51:38 But we have options also for other cerebrovascular disease, an unspecified cerebrovascular disease. So my thought was if we don’t know we know it’s vascular dementia. Why can’t we use unspecified, cerebrovascular disease as the underlying cause?
51:54 If we, if they don’t know, specifically, know, the specific cause, but they know it’s, you know. Maybe they have some they have they think that it’s vascular a possible probable vascular dementia.
52:08 Can we use I 67.9, if they don’t know? That was kind of my thought process as I was trying to figure this out.
52:16 We, I’ve had two cases in the last, I don’t know, couple of weeks where it was a case was queried and the doctor said, I don’t know the cause of the vascular dementia, um, but you diagnose the patient with vascular dementia, so that didn’t really make much sense to me.
52:33 And that was our Principal Diagnosis because they came in with some, the vascular dementia behavioral disturbance due to the vascular dementia and we have to code an underline. It’s not like if.
52:43 If known, it’s not one of those, if knowns this is specifically states code first, the underlying physiological conditions you’ll also get.
52:51 When you’re in your encoder, you’ll also get it can’t be the first listed diagnosis you’ll get an edit Saying it can’t be first.
53:02 OK, so let’s go back here, so that was my thought process because if we go to Disease brain and we go to Arterial, it takes us to I 60, 79. If it’s arterials corrado, it takes us to I 67.2, which we just looked at. And then also if we go to Disease, cerebrovascular, we know it’s a vascular dementia, right. So if we go to a disease cerebral, it says to see Disease Brain, which, again, will take us to this one of these codes But then if we go to disease, cerebrovascular, unspecified as ice 67.9, and then, of course, there’s some more options here, if it’s further specified.
53:41 Yeah.
53:41 So, in the comments, I’m just looking at what others are doing in it.
53:48 Multiple choice query. Query for meaning of vascular dementia using options. So that’s my recommendation. For anyone that’s struggling not just to leave it open ended because I think the providers aren’t understanding what we’re asking. What do you mean? They have vascular dementia.
54:04 It’s vascular dementia. So, I mean, those are some of the options that I suggest. Obviously, not all of these make sense but I think or let me go back.
54:13 These make sense to me, you know, disease of the brain. Cerebrovascular disease, you know, is it chronic Arturo Scholastic? Is it ischemia?
54:25 Other, you know, you always wanna give another or other option, but we kind of shouldn’t, I mean, we should always, clued an opt out option, but in this case, we really can’t because we need to know. So, to me if they say unspecified, cerebrovascular disease, it’s kind of like, an opt out option.
54:42 Because they’re saying it’s vascular, or we can just say, other type of dementia as the opt out option because then, that gives them the, the option to say it’s not. It’s not vascular dementia and at some unspecified dementia instead.
54:58 But, yeah, I think that’s kind of like, the newest issue that I’m seeing with our vascular dementias.
55:04 Um, it’s actually, maybe it’s not new, but it’s an issue that I just wanted to bring up. Because it’s, I don’t know, if for some reason, just over the past couple of weeks, it’s become more, more of an issue.
55:16 Um.
55:20 So, if you’re so bored or you’re not leading the provider because they say the patient has vascular dementia.
55:27 So, if you give options that make sense, that, you know, take a look at the Hema Query Toolkit, if you need to, you know, we’re not saying we’re not giving them we’re not saying does this patient had Huntington’s disease? That wouldn’t make sense? Because that’s not a vascular dementia. We’re giving them all options for different types of vascular dementia.
55:49 We can, we are allowed to give multiple choice queries, right?
55:53 And we’re only giving options that are related to vascular diseases of the brain.
56:09 Yes. Sometimes it is an issue where it’s previously been diagnosed by another provider.
56:18 So, I mean still we have the option to ask Cerebrovascular disease, not otherwise specified and then we can kind of, we can use the I 60 79.
56:29 Mmm hmm.
56:30 Then we can also give other dementia Please specify the, you know, the type of dementia you think the patient has.
56:38 I’m thinking they have their own, you know brainpower that they’re they can say.
56:42 I don’t think this patient has cerebrovascular hyper or, you know, stroke dementia.
56:48 But anyway, I’m just kind of going on our honor.
56:54 Side note there. But anyway, I know that’s an issue. It’s something that, it’s kind of been on my mind lately, how do we solve this issue. And, that’s kind of what I came up with. Let me know in the comments if you guys are doing anything else, or how you’re addressing it at your facility.
57:11 Again, I’ve seen it two times in the last couple of weeks, so, I know it just can’t be me and coders that I’m working with experiencing this.
57:22 OK, Same with dementia, diseases classified, elsewhere, kind of moving on. I have a couple more minutes. Again, we have the width guideline.
57:33 Mild, with, on the same will furby moderate with severe with, but because of the width guy night, we can assume the relationship.
57:45 Um, and it also, dimension diseases classified elsewhere includes major cognitive disorders and other diseases elsewhere.
57:53 We see here that it excludes mild neurocognitive disorder. So, remember, we’re talking about the definition.
58:01 We’re talking about the definition of, of dementia and mild cognitive mild neurocognitive disorder is where the patient hasn’t yet progressed to dementia.
58:13 So, if they have progressed to dementia, we shouldn’t be coding both mild and major neurocognitive disorders. So I just wanna point that out.
58:24 And please note, patients can have multiple causes of dementia.
58:28 You know we there is, you know someone can have all zimmer’s dementia and they can have vascular dementia.
58:34 There is a note here for diseases Unclassified elsewhere.
58:39 That we have an excludes too for vascular dementia. If someone has Alzheimer’s dementia, they can also have vascular dementia.
58:46 So code first, the underlying physiological condition this one’s a little bit different, a little bit easier, because we have dementia and other diseases classified elsewhere.
58:54 So we know that’s a manifestation code and then look at all the options we have for different conditions that can cause dementia. We saw the focus was on Alzheimer’s, Parkinson’s, and Lewy bodies Frontotemporal Dementia. HIV is another one Huntington’s disease.
59:15 Some of these are quite rare, like, the prion diseases, this Jacob Creutzfeldt disease, it’s quite rare.
59:22 You know, subprime prion disease, MLS, traumatic brain injury, that’s probably going to be a … code.
59:32 We see that with our what are, um, our traumatic brain injuries with dementia that progress with our fighters are, you know, NFL players, things like that.
59:45 Do you have recurrent brain injuries?
59:49 So, I just wanted to point out, again, it’s still set up like all the other categories, dementia, unspecified severity with our anxiety, mood disturbance, psych psychotic, disorders, disturbances, and of course the same definitions here. And then our use additional code to identify wandering, if applicable.
60:11 But, just, you know, we want to make sure we’re also sequencing our underlying condition first, followed by R F 0 2 code, depending on what code they have.
60:27 Ah.
60:31 So, someone is asking is there a code for CTE krajina I think that’s chronic traumatic encephalopathy. I don’t think there is.
60:41 It’s probably like other with probably a … code for the traumatic brain injury or whatever injury patient had.
60:49 That’s a good question.
60:50 Off the top of my head, I don’t know the answer to that, but I’m assuming, if I’m thinking through the process, um, I don’t think there is a specific code for that.
61:04 They definitely need to create one. Right, if there isn’t.
61:10 OK, so so in saying, How do we code Parkinson’s complicated by BP S D? So we would code first, our Parkinson’s disease, right?
61:20 We can go through the index, if I can bring it up.
61:23 And then we’re going to code, I think it’s dimension diseases classified elsewhere, right? So we have our Parkinson’s. Where is it to dementia with Parkinson’s, or an encode G 3183, and then dementia, and what was the you asked?
61:40 Uh.
61:46 Sorry, I’m trying to find that question again.
61:55 Yes, they do. I don’t know, I don’t have my book open, So I don’t know if there is one or not.
62:01 So if they have B P S D, so I would have to know the specific specific behavioral disturbance or so, let’s say it’s with behavioral disturbance.
62:14 You’d go to F O two. We code the G 3183 followed by R F O 281, and then whatever the major behavioral disturbances.
62:31 OK?
62:35 Remember, because it says, Decode First, the underlying disease, right?
62:39 That would be one where we encode first the Parkinson disease, followed by RF zero to code.
62:51 Then, we have our Alzheimer’s disease, we have our G 30, and then we, this is where we’re talking about early onset late onset. Some people said that, they saw that more than actually, if it’s mild or moderate. So someone asked about Parkinson’s, I kind of use … as my scenario.
63:07 But the same thing with Alzheimer’s, right, We’re going to code the G not 30.9, and then we see in the brackets we’re going to use an additional code, FO 2 8 1 depending on what, exactly, um, what, exactly the severity, and also the behavioral disturbances. So if we go to dementia and diseases classified elsewhere, we have to pick the appropriate behavioral disturbance in order to assign the correct code.
63:34 The same thing with Parkinson’s disease.
63:40 And I can bring up my code book in just a second and show you guys show you that. So, we also, I want to, I talked about this earlier in the presentation delirium. So as you can see, this includes delirium superimposed on dementia. Those F, those F 0, 2 8 oh codes are other codes for, don’t include the delirium, that’s a separate, a separate code. This includes FO five includes delirium, we have that excludes to note, right? We have the delirium superimposed on dementia.
64:11 So we can, don’t forget, we can also code the F 0 5 if appropriate.
64:16 It says code first, the underlying physiological condition. So, if it’s dementia or in a sequence that dementia first followed by the F 0 5.
64:28 Millimeter and then just whoops.
64:31 Then just a reminder about all of our C Cs. A maggot basically done with the presentation. You guys don’t have to stay. That was basically the overview of what we’re going to talk about.
64:40 Just to kind of sum up what we talked about, all of the vascular dementia codes with behavioral disturbance, all of dementia disease classified elsewhere with behavioral disturbance, mild, moderate, severe, unspecified dementia with agitation, with psychotic, disturbance, Mood Disturbance, et cetera. Those are all C Cs.
65:04 Kind of if you think about the code that we had before with behavioral disturbances, those were the C Cs. But because of the expansion, these all become CC, so we have a ton more codes for CCS related to dementia, so we should be looking out for these different types of behavioral disturbances.
65:21 Of course, we do have a guideline update reserve revolving dementia.
65:26 The ICD 10 CM classifies dementia, on the basis of etiology and severity, unspecified, mild moderate severe. Selection of the appropriate severity level requires the providers, clinical judgement and code assignment should be based on the base of the provider documentation, unless otherwise instructed by the classification.
65:43 So, going back to my question, and we talked about this before in another presentation, with advanced dementia, be coded to severe. There’s no indexable way to get advanced dementia to code severe severity. The provider would have to tell us that advanced dementia equals severe dementia based on this guideline.
66:04 You can always query for that or just code the unspecified and it just says that in the guideline, if the documentation does not provide information about the severity, we’re just going to go with unspecified.
66:16 Then, if admitted to an inpatient acute care hospital or other inpatient setting, if they progress from one severity level to a higher severity level, we’re going to assign the code for the highest severity level in our reporting.
66:34 And the question that I’m throwing out here is, What are the challenges you you are having?
66:39 I somehow I have a typo there. What are your challenges with coding dementia? I have to fix that.
66:45 And then, just our references, where you can get all the information about dementia, the background, why the codes are created, and things like that are in both of these documentation or both of these packets for the co-ordination and Maintenance Committee meeting. And then, of course, I know I’m going to get a ton of questions about CEUs. You can download your CEU Certificate by visiting the … Health website. The link is on the is within the handouts and also on the screen at this point.
67:13 And you have two weeks from today to download the CEU certificate before the link expires. And please allow time, we’ll give the link to the CEU as a as a courtesy because not for summary. For some people they don’t receive our e-mail as we do. send a follow-up e-mail with the link once the CEU’s ready. So please allow time before you send us an e-mail, saying that the certificate isn’t available. This is just as a courtesy, in case you don’t get our follow-up e-mail, because your facility blocked it, or whatever reason you didn’t get the e-mail. And, we do track attendance, in case anyone request that, and that you’re here for at least 45 minutes. We do, we are, we do know how long you’re in the webinar.
68:01 And, of course, our ex employees please refer to Yammer for guidelines regarding CEUs.
68:09 So, I’m going to stay on for questions as per usual, but I just wanted to end the webinar officially because we’re out of time. But, let’s take a look at what the questions are. So, the question was, going back to.
68:29 The question about C T E.
68:42 For CTE and suffer traumatic hoods to OK. So I wasn’t sure I couldn’t remember.
68:46 So traumatic encephalopathy, traumatic codes to F O 7, 8 1 post concussion syndrome, which a coat a no to coat. First, F O seven.
68:57 F O seven To Code First, Underlying Physical. Psychological Condition, OK. Thank you, that now it rings a bell, I haven’t looked that up in a long time.
69:05 OK, thank you.
69:08 Is there one for Dementia?
69:11 I don’t have to open up my code book.
69:16 As I mentioned, someone’s mentioning that the date is wrong, that’s the preview. You need to wait for us to upload the new CEU. That’s again a courtesy. We’ll be sending out an e-mail once that everything’s available. So please wait a little bit before you go ahead and download that CEU.
69:33 Um.
69:37 So this is a good question.
69:38 I’m still waiting for first, actually for first quarter, First quarter, our Coding Clinic to come out, know if we have an additional information regarding the anxiety, either behavioral disturbance. Do we also add a code if it offers more additional detail? Do we also add a code for the specific anxiety or depression?
70:02 That’s a great question.
70:04 I don’t know. I don’t know the answer to that.
70:06 It looks, you know, for now, I probably wouldn’t, but I don’t, I mean, I don’t, This is just a random person, so I’m not an official source, because, they don’t say, to add an additional code, and I’m probably, I’m thinking that it would be included, but I’m not 100% positive on that.
70:24 So, I would discuss that with your facility and see if, see, kind of, how they’re handling that.
70:30 OK. So, going back to the vascular, the vascular, the Parkinson’s dementia, let’s go to the code book. I’m going to bring up the code book.
70:39 Actually, that’s, um, yes.
70:46 I’m looking for the index. Let’s go to Parkinson’s.
70:55 It’s far easier if I search.
71:01 Being slow, sorry.
71:21 I spelled it wrong.
71:28 OK?
71:37 Oh, This is probably the easiest thing to use when you’re trying to look it up.
72:01 Sorry, it’s just being really slow.
72:07 I’m going through my index.
72:12 Right.
72:22 So, what I’m trying to do.
72:30 So.
72:33 With dementia, it says C, G 20. What does it say in our book? It’s a G 20.
72:42 They look at that wrong.
72:49 OK?
72:56 Sorry. I’m going back to what they said.
73:05 They’re Coding Clinic on this.
73:08 I think there’s a coding clinic on this that says to use the G because, one way you index it, it goes to G 20, the other way it goes to, you think they would have fixed that.
73:19 Let me bring, I have to bring up Coding Clinic.
73:44 Ah!
74:01 I’m just bringing up Coding Clinic Isere, I’m trying to open it, so I can answer your question, but I think there is a coding Clinic on you know, one way you index it. It goes to the G one G code the other way it goes to G 20. I could be wrong though.
74:17 I don’t want to speak without looking it up first, like I did with the GT, the CTA mm.
74:33 OK.
74:41 Um.
74:46 Yeah, so just to comment, while I’m waiting for my three AM to come up.
74:56 I don’t know without seeing the whole Coding Clinic, Nicole, thank you though. It’s the one with the Geo three. I don’t, I just remember, there’s something on it. So just a comment. So someone commenting that there’s a combo code or when they’re coding the combo code with anxiety, they’re not assigning an additional code for anxiety, MLS.
75:17 But maybe they are for, like if it’s more specified, like the GED, which is, it makes sense to me, I just don’t know if that’s like official.
75:27 If it’s offering more, more advice, or more not more advice, more specificity with the diagnosis, it makes sense to add the specific code. I just don’t know if that was the intent of the codes.
75:47 OK, let me see if I can get this up, so I can find that Coding Clinic Sorry, when I’m on a presentation, sometime.
75:54 it, it.
75:56 It kind of takes up too much bandwidth, and I can’t open things, so.
76:03 Yeah, I can’t open it right now. I think. So guys, if you have access, it’s not letting me in. So if you guys have access, I would look, look that up. I think it’s either G 20, or the G, the one that’s in the code book, which I, I can’t remember which one exactly, But, then you’re also going to assign the additional F, zero to in addition to the code for Parkinson’s disease.
76:32 Let me see.
76:42 Oh, God.
76:52 So, dementia with anxiety Me see here.
76:58 So it’s unspecified, dementia.
77:03 I’m going to assume that it’s unspecified, dementia.
77:06 Let me think this through. Sorry, I can’t I don’t have. So unspecified dementia with anxiety.
77:16 Unspecified severity.
77:20 With anxiety and depression Can I should I assign dementia with mood disturbance and dementia with anxiety.
77:33 I’m trying to understand the question.
77:41 So, normally, we don’t, I think I’m understanding, so normally we don’t code the combination code, right?
77:47 We anxiety is documented. Depression is document it. We code those out separately, right?
77:55 Um, there’s a coding clinic on that.
77:58 Um, we don’t automatically link those two together so if they have anxiety and they also have dementia, I mean depression, then I’m gonna assign the SO 3.
78:09 9, 3, then I’m also going to assign the FO 3, 9, 4.
78:14 Now things ID is N O S.
78:17 I’m not going to assign a different another anxiety code, right? It doesn’t offer any additional detail.
78:24 Now with the mood disturbance, this is where they don’t give us advice, right? They don’t tell us assign a different additional code for the mood disturbance, which based on coding guidelines, I would say you can assign an additional code. Although it isn’t the, it is in this description depression.
78:45 So that’s actually a good question. Is the intent for us to also assign that, you know, additional depression code, which, based on, again, coding guidelines, If that code is going to offer additional detail, we can go ahead and assign that as additional additional detail. So I hope that answers your question, Laura.
79:13 It is inconsistent. They have a coding clinic on that.
79:22 Oh, thank you, I think you supplied me the Coding Clinic. Thank you. I thought that was your question. Answer, code G 20. Parkinson’s disease, and F, O, 2, 8, 1 dimension, other diseases classified elsewhere.
79:35 Um.
79:38 OK, so it says …, Assign the G 20.
79:44 Isn’t there a nut, there’s a second one, isn’t there?
79:47 The Centers for Disease Control CDC are aware of the inconsistencies and the alphabetical index and are considered considering possible modifications for the indexing of this condition. So I wonder if they fix that for this year, I’m going to have to look into that. Thank you for giving me that Coding Clinic. I appreciate it.
80:05 It’s a good question. So Parkinson’s, dementia versus Parkinson’s, and as a question, a patient is diagnosed with dementia. I think this is the same one.
80:15 Depending on how you index it, you can get G 20 versus, oh, the G 30, 183, Parkinson dementia with Lewy bodies.
80:24 So they do tell us to use the G 20.
80:27 OK. So going back to your question, based on that Coding Clinic before this code was changed, I would use the G 20, and there are they are considering changing the index. So I know we usually follow the index, but it’s inconsistent depending on how you index it in the index. I do have to look dive into the code book and see if they did make any changes. I have to look at the agenda and see if perhaps they didn’t make any changes to Parkinson’s is ISM. I didn’t notice that specifically. I’m surprised they didn’t make the change while they were making the changes to dementia codes. I find that to be surprising, so I’m gonna look into that a little bit more, but that’s based on the coding coding clinic.
81:12 Um, Yep. So, DSM five classifies anxiety separately from mood disorders, including depression. Yep, so does ICD 10.
81:29 I was answering someone’s question regarding that. There is a combination code for anxiety.
81:34 When they’re linked, they’re saying it’s depression, you know, causing anxiety. We do have a specific code for that. I would look for that specific documentation.
81:44 I don’t remember the code off the top of my head.
81:54 OK, I think we’re a bit out of time here, already 20 minutes after, I think I got to most the questions, if I didn’t get your questions.
82:05 We can always do a follow up. I’ll look through the questions. I think I answered most of the questions, at least if someone, at least, or actually probably all of the questions.
82:19 I answered the CEU question multiple times, so I’m not going to answer that again.
82:23 Um.
82:32 So, I did go back and circle back to the advanced Dementia, I’m not sure if this was when you asked the question, but I would not assume based on that. When I was going over the guidelines, I would not equate advanced dementia to severe dementia base. We can’t index advanced dementia. It’s not in the definition in our code books. I would still, I think a query is needed for that.
82:58 That could be a good coding clinic question. Maybe they’ll say it is equivalent to severe dementia.
83:13 So, what would you code if the doctor documents chronic infarction? So, that would be a …, right? So, if they have dementia due to a chronic infarction, that would be a … code, we can use, like a sequela code for that. And again, I apologize. I 69 code, Apologize, I don’t know. The code off the top, my head for that, I 69. Something.
83:49 I think I answered all of them. Again. There’s quite a few comments here. For whatever reason, I didn’t, you can always send us an e-mail. And I’ll try to get back to you on those. So, anyway, everyone, have a great day and we’ll see you next time.
84:06 And for anyone still having questions about CEUs, I did mention it in the last in the slide deck if you want to download the handouts. Or if you already downloaded the handouts information’s on the slide deck, also. We do send a follow-up e-mail.
84:20 With a link to download, reduce supply, the the link for CEUs as a courtesy. Please give us time to upload that CEU for this webinar. Thank you.