CUTE AS A BUTTON

September 8th, 2017 by Dr. G. Moak

It happened again!   A psychiatric nurse, well experienced, well trained, and well meaning, described the newest admission to our service, a ninety-year-old, very frail looking woman with severe dementia, as “cute as a button”. Hearing this, I cringed. Not only because this nurse said it, but also because it’s commonplace in so many healthcare settings, including specialized geriatric programs, where staff members ought to know better. They don’t!

I know this nurse well. She really cares about the older patients on our geriatric psychiatric service. She’ll go out of her way to ensure their needs are met. I’m sure she means to treat them with the dignity and respect they deserve. So why does she not understand that describing geriatric patients as “cute as a button” is not a good way to do this? Why do so many other equally well-meaning healthcare professionals describe frail elders as cute? And is there anything truly cute about advanced, old age?

Toddlers, puppies, and kittens are cute, little old ladies and men not so much. I doubt that you know anyone hoping to be cute in old age? Quite the opposite, they want to avoid that fate, maintaining their dignity and independence. Think about what old-age “cuteness” signifies. It signifies that formerly robust, capable, independent adults have turned into shrunken, frail, feeble, confused waifs with elfin or gnomish qualities. Not an attractive picture.

My guess is that seeing such elders as cute is a defense mechanism for healthcare workers, a way they can ward off their own fears of decrepitude triggered by close proximity to frail patients nearing death. Emotional contact precautions, that’s what it is. It says, “You’re infected with old age, and I don’t want to catch it”. Contact precautions work by providing a barrier, blocking infection. “Cuteness precautions” provide a barrier too, blocking the emotional reality check staff members need to empathize with older adults and help them maintain their dignity. When you’re ninety years old, there’s nothing dignified about being cute.

We teach cultural competence to healthcare professionals to help them be more sensitive to the personal needs of all kinds of patients. Isn’t it about time we added elderly patients to the list?

DOES STICKING TO LOCAL TRIPS IMPROVE OLDER DRIVERS’ SAFETY?

March 20th, 2017 by Dr. G. Moak

I’ve heard it hundreds of times: “But I only drive locally, in familiar neighborhoods!” That’s how my patients try to convince me that it’s still safe for them to drive. Their family members similarly rationalize, “But Dad only drives three places, the bank, the post office, and the supermarket. He knows the way very well and doesn’t get lost!” People assume that limiting driving to short, local, trips is a good way for older drivers with declining abilities to remain safe behind the wheel. It makes common sense, but it is not correct.

My patients and their families are always surprised to learn (and you might be too) that driving fewer overall miles, generally by sticking to local routes, doesn’t lower an older driver’s risk of having an accident, it raises it. Drivers over sixty-five years old, on average, have higher accident rates than younger drivers, but older drivers who drive more than 3,000 km (just under 1,900 miles) per year have lower accident rates, equivalent to those of middle aged individuals.

What’s going on here? Why isn’t driving fewer miles and keeping to shorter, local roads, safer? Shouldn’t short, familiar routes be easier for forgetful older adults to remember? Of course, but much more goes into safe driving than memory. Navigating local streets demands more of drivers than does highway driving. There’s more to deal with: more signs, more turns to make, traffic lights to obey, more intersections to negotiate, and more parked vehicles, bicyclists, and pedestrians not to hit; in short, more opportunities for error.

Being able to remember the route and recall details on the way, such as speed limit, of course, are important. But it is the ability to take note of, and quickly react to, a complex and rapidly changing landscape that determines safety most. Aging takes a toll on the mental abilities needed to stay vigilant, anticipate the unexpected, properly judge the speed and distance of other vehicles, and make quick decisions about passing, pulling out, and yielding the right of way. This shows in the types of crashes that older drivers most commonly have: left turns across traffic, failure to yield the right of way, failure to stop at a signal, and failure to judge speeds correctly. Intersection crashes account of two fifths of crashes involving senior drivers versus only one fifth of those of younger drivers.

So rationalizing that it’s still safe for an older adult to drive because he or she only drives locally may be just that, a rationalization. Each person’s abilities, fitness, health, and circumstances are different, and obviously there are exceptions. But if an older adult has given up longer distance driving due to worries about safety, then keeping to shorter, local routes may not be any better.

References

R Robertson and W Vanlaar, “Elderly Drivers: Future Challenges”, Accident Analysis & Prevention 2008; 40: 1982-1986.

J Langford and S Koppel, “Epidemiology of Older Driver Crashes: Identifying Older driver Risk Factors and Exposure Patterns”, Transportation Research 2006; Part F, 9: 309-321

Think Medications for Dementia Produce No Meaningful Benefit? Don’t Be So Sure

January 14th, 2017 by Dr. G. Moak

Currently available anti-Alzheimer drugs – donepezil (Aricept), galantamine (Razadyne), rivastigmine (Exelon), and memantine (Namenda) – are not the miracle cures patients hope for, and many clinicians are skeptical, and don’t prescribe them. Consumers nevertheless have heard that these drugs at least “slow it down”, and many accept this as better than nothing.

But do anti-Alzheimer medications “slow it down”? Unfortunately, scientists do not know for sure. Some research demonstrates actions in the brain of anti-Alzheimer drugs that could be helpful, but there has been no proof that these effects interrupt the disease process. Specialists who recommend these medications mostly believe that their benefits are limited to temporary improvement of symptoms, stabilizing their patients’ conditions for a time, before they resume relentlessly losing ground to dementia. What remains unknown is whether treated patients continue to decline at the same rate as before or slower. A new study provides reason to think that anti-Alzheimer drugs actually might slow down patients’ decline.

Last month French researchers published a study of patients with mild cognitive impairment.*  Mild cognitive impairment (you may hear it referred to as mild neurocognitive disorder) is a milder condition not severe enough to be considered a dementia. About half of the time, however, MCI is a preliminary stage of Alzheimer’s disease: such patients gradually get worse and sooner or later develop dementia.

In this French study, patients with MCI were treated for one year: half received donepezil (Aricept) and half placebo. At the beginning of the study, and again at the end of the year, patients had brain MRI scans, and the thickness of their cerebral cortex was measured. The cortex is the outer layer of the brain, where memory and other higher mental abilities reside. As Alzheimer’s disease worsens the cerebral cortex gets thinner and thinner. Researchers compared the amount of thinning in those who received donepezil with those who did not. The good news is that the patients treated with donepezil had much less cortical thinning than those who received placebo. In some brain areas, the cortex even got thicker! This finding suggests that treatment with anti-Alzheimer medications may actually slow down the rate at which patients decline

While encouraging, this study has many weaknesses, so it is far from a slam-dunk proof of anything. But it does provide another bit of evidence that anti-Alzheimer drugs may not be as worthless as many think. If these drugs do slow the rate of decline, the benefit might not be apparent early in treatment, but would be more and more obvious, and meaningful, as time goes on because patients stay further and further ahead of where they would have been without treatment. This is a different way to think about medical treatment, but nonetheless a meaningful one, especially for Alzheimer patients and their families.

Dementia, By Any Other Name, is Still Dementia

November 22nd, 2016 by Dr. G. Moak

Have you adopted the DSM-5 nomenclature “major neurocognitive disorder”, or have you continued to use “dementia”, as I have? DSM-5 was released in 2013, introducing neurocognitive disorders, major and minor. In the years since, I’ve noticed that many psychiatrists, but not all, have adopted the new nosology. But other physicians, including primary care physicians and neurologists, and most geriatric psychiatrists, still use “dementia”. And ICD-10 uses the tried and true term “dementia”. Nevertheless, as a medical school faculty member, responsible for the training of medical students, residents, and fellows, I suppose I should toe the DSM-5 line, but I’m not going to do it. It’s a pet peeve.

It’s almost 2017, and you might wonder what took me so longer to get around to expressing my objections to the reclassification of dementia as a neurocognitive disorder. Fair question. Suffice to say I’ve been busy. “What could have been more important this this?” you ask. For one, there’s Medicare, moving target par excellence, source of endlessly changing rules, regulations, and (dis)incentives, and general bane of existence. And then there’s my book, Beat Depression to Stay Healthier and Live Longer: A Guide For Older Adults and Their Families, published earlier this year. It’s a terrific book and easy to read, if I do say so myself. I assure you that nary a page deals with ICD-10, but there is a terrific chapter, suitable for the lay public and clinicians alike, on the differential diagnosis of depression, covering the different types of depression, other conditions that masquerade as depression, and how to tell them apart. Ironically, I used DSM-5 terminology. I’d highly suggest getting a copy: no, not DSM-5, my book! Even before you finish reading this post, you may wish to order it on amazon.com.  You won’t regret buying my book, but, back to DSM-5 and dementia.

First my “minor” major neurocognitive disorder objections. I simply like the term “dementia” better. It’s traditional, having been in use for well over 100 years. Healthcare professionals all know what it refers to, and much of the public does. And it’s shorter and easier to say. “Major neurocognitive disorder” doesn’t exactly roll off the tongue.

And now my “major” major neurocognitive disorder objections. Actually I don’t object to “neurocognitive” for the category of syndromes, generally, but I don’t see the advantage for dementia specifically. True, “neurocognitive” does describe a major aspect of dementia. But is also seems too narrow, the most disruptive and disabling manifestations of dementia being their psychiatric and behavioral complications. And, and the same time, it also seems non-specific, schizophrenia clearly also being a disorder involving severe neurocognitive impairment. Had they asked me, I’d have suggested letting dementia be dementia, and calling the category of disorders “acquired disorders of widespread brain impairment usually first manifest in late life”. Nobody asked me, but, no matter, there’s always DSM-6 to look forward to.

What do you think? Send me a comment, and let’s start a discussion.   If you’d like to receive my online newsletter, please navigate to the contact page and leave your email address.

ICD-10 CODING FOR PSYCHOSIS IN ALZHEIMER’S DISEASE

October 24th, 2016 by Dr. G. Moak

Here’s a common question:  What is the proper ICD-10 code for psychosis in Alzheimer’s disease?

The Bottom Line

Here are the appropriate diagnoses in the order they should be listed on your claim form:

G30.1, Alzheimer’s disease, late onset (G30.0 for early onset)

F06.2, psychotic disorder with delusions due to a known physiologic condition

F02.81, Dementia in other diseases classified elsewhere, with behavioral disturbance.

Read on if you’d like a more detailed explanation and an ICD-10 pearl.

Background

Prior to DSM-IV-TR, 290.20 was the accepted code for dementia of the Alzheimer’s type, with delusions.  Using this code was straightforward: it was the only code you needed, and it was both a DSM-IV AND an ICD-9 code, so you couldn’t go wrong (Recall that Medicare accepts ICD codes, and does not recognize DSM).  Since the advent of ICD-10, many psychiatric providers, long accustomed to entering a single diagnostic code, have been using F02.81, dementia in diseases elsewhere classified, with behavioral disturbance.  The problem with this is that, standing alone, this code does not adequately capture the intensity of service usually required to treat the psychiatric complications of Alzheimer’s disease, especially when hospitalization is warranted.   To appreciate why this is the case, we need to understand something about Part B Medicare reimbursement.

Medicare Claims Coding 101 

Original, fee-for-service Medicare has no prior authorization or concurrent review.  Claims are paid when the diagnosis code matches the CPT service code and level of service provided, supporting the medical necessity of the services billed.  In a Medicare claim, the diagnosis essentially is a proxy for the reason for the service.

Consider the case of an elderly man with Alzheimer’s disease with paranoid delusions and homicidal ideation, admitted to a geriatric psychiatry inpatient unit for threatening his wife with a shotgun, convinced that she’s trying to poison him and run off with a lover he’s conjured up in his delusions.  He repeatedly expresses his intention to kill her, and there is no doubt that psychiatric hospitalization is medically necessary.  But psychosis with homicidal dangerous is the reason, not Alzheimer’s disease.  F02.81, dementia in diseases elsewhere classified, with behavioral disturbance doesn’t convey this effectively: it’s nonspecific, saying nothing about symptoms, severity, or acuity.  Fortunately, other ICD-10 codes can be added to paint a more vivid and representative picture.

ICD-10 Coding for Psychosis in Alzheimer’s Disease

The F06 series of codes, other mental disorders due to known physiologic condition, can be used to code the various psychiatric complications of dementia.  This group includes distinct codes for mood disorders, both depression and mania, anxiety, and psychosis. There are three codes for psychotic illness that might apply to psychosis in Alzheimer’s disease: F06.0, psychotic disorder with hallucination due to known physiological condition, F06.1, catatonic disorder due to known physiological condition, and F06.2, psychotic disorder with delusions due to known physiological condition.  It is permissible to code as many as apply; up to twelve diagnoses can be listed in an ICD-10-compliant claim. In our hypothetical case, we would add FO6.2 to the diagnoses.

We’re not done yet.  Both F02.81 and F06.0 are manifestation codes, meaning they are conditions caused by one or more specific etiologies.  ICD-10 distinguishes manifestation codes from etiology codes.  Manifestation codes are recognizable by phrases such as “in other diseases classified elsewhere”.  Whenever you use a manifestation code, you must accompany it with one or more etiology codes, and these must be listed first.  Dementia is a syndrome with multiple causes so F02 is thus a manifestation code.  In our hypothetical case scenario, the underlying diagnosis is Alzheimer’s disease with late onset, the ICD-10 etiology code for which is G30.1. Two other common causes of dementia that have etiology codes that pair with F02 are G31.0, frontotemporal dementia, and G31.83, dementia with Lewy bodies.

Here’s an additional coding pearl.  In ICD-10 there is a code “homicidal ideations”, R45.850.  Surprisingly, this code is nowhere to be found in DSM-V, not even in the appendix of relevant ICD-10 diagnoses.  No matter, we can use it. Adding it to the diagnoses helps your claim more fully reflect the medical necessity of the services rendered.  So, this is how you could list your diagnostic codes for our patient:

G30.1, Alzheimer’s disease, late onset

F06.2, psychotic disorder with delusions due to a known physiologic condition

R45.850, homicidal ideations

F02.81, Dementia in other diseases classified elsewhere, with behavioral disturbance.

Did You Find This Helpful?

If you found this post helpful, are there other topics in the area of Medicare billing you would like to see covered?  Please send me a message, letting me know, and, while you’re at it, tell me if you’d like to be added to the email list for the Moak Mental Health and Aging Report.

Disclaimer

Information in this blog reflects my understanding of current Medicare rules and regulations.  I used these codes regularly in my practice, and encountered no problems, but following my advice is no guarantee of error-free coding and audit-free payment.  All providers are ultimately responsible for Medicare compliance and correctly coding their claims.  Good luck and godspeed!

Gary S. Moak, M.D.

Practice Management Consultant, Moak Associates

Author, Beat Depression to Stay Healthier and Live Longer: A Guide for Older Adults and Their Families

Assistant Professor of Psychiatry, Geisel Medical School at Dartmouth

Chief of Geriatric Psychiatry, New Hampshire Hospital