Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Hospice Bulletin 12 February 2018 TO: Hospice Providers Participating in MassHealth FROM: Daniel Tsai, Assistant Secretary for MassHealth RE: Changes to MassHealth Policy on Diagnoses That Are Not Appropriate for Reporting as Principal Diagnoses on Hospice Claims Background As of October 1, 2014, the Centers for Medicare & Medicaid Services (CMS) provided an update regarding, among other changes, new editing instructions for diagnoses that are not appropriate for reporting on hospice claims. CMS Transmittal 3032, available at , provides the following guidelines: Hospices are to report diagnosis coding on the hospice claim, as required by Coding Guidelines. The principal diagnosis reported on the claim is the diagnosis most contributory to the terminal prognosis. ICD-10-CM Coding Guidelines state that codes listed under the classification of are Symptoms, Signs, and Ill-defined Conditions not to be used as principal diagnoses when a related definitive diagnosis has been established or confirmed by the provider. Hospice providers may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-10-CM Coding Guidelines and require further compliance with various ICD-10-CM coding conventions, such as those that have principal diagnosis code sequencing or etiology/manifestation guidelines. Changes to MassHealth Policy on Diagnoses That Are Not Appropriate for Reporting as Principal Diagnoses on Hospice Claims MassHealth’s policy pertaining to diagnoses that are no longer appropriate will follow the CMS guidelines. Effective upon the date of this bulletin and in accordance with the above referenced changes to the CMS hospice rules: The principal diagnosis reported on the claim should be the diagnosis most contributory to the terminal prognosis. Hospice may not report ICD-10-CM–Z codes as the principal diagnosis on hospice claims. Both “debility” and “adult failure to thrive” are considered nonspecific, symptom diagnoses according to ICD-10-CM Coding Guidelines. (continued on next page)
Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Hospice Bulletin 12 February 2018 TO: Hospice Providers Participating in MassHealth FROM: Daniel Tsai, Assistant Secretary for MassHealth RE: Changes to MassHealth Policy on Diagnoses That Are Not Appropriate for Reporting as Principal Diagnoses on Hospice Claims Background As of October 1, 2014, the Centers for Medicare & Medicaid Services (CMS) provided an update regarding, among other changes, new editing instructions for diagnoses that are not appropriate for reporting on hospice claims. CMS Transmittal 3032, available at , provides the following guidelines: Hospices are to report diagnosis coding on the hospice claim, as required by Coding Guidelines. The principal diagnosis reported on the claim is the diagnosis most contributory to the terminal prognosis. ICD-10-CM Coding Guidelines state that codes listed under the classification of Symptoms, Signs, and Ill-defined Conditions are not to be used as principal diagnoses when a related definitive diagnosis has been established or confirmed by the provider. Hospice providers may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-10-CM Coding Guidelines and require further compliance with various ICD-10-CM coding conventions, such as those that have principal diagnosis code sequencing or etiology/manifestation guidelines. Changes to MassHealth Policy on Diagnoses That Are Not Appropriate for Reporting as Principal Diagnoses on Hospice Claims MassHealth’s policy pertaining to diagnoses that are no longer appropriate will follow the CMS guidelines. Effective upon the date of this bulletin and in accordance with the above referenced changes to the CMS hospice rules: The principal diagnosis reported on the claim should be the diagnosis most contributory to the terminal prognosis. Hospice may not report ICD-10-CM–Z codes as the principal diagnosis on hospice claims. Both “debility” and “adult failure to thrive” are considered nonspecific, symptom diagnoses according to ICD-10-CM Coding Guidelines. (continued on next page)
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