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

Depression and Frailty

October 1st, 2016 by Dr. G. Moak

Imagine a feeble, old man. Is he stooped, gaunt, thin or wasting, shuffling along slowly, relying on a cane to avoid falling? Does he seem exhausted, tentative, insecure, or weak? And is he mentally sluggish or easily confused? This fragile and vulnerable picture is that of frailty.

Much of the public believes frailty is a normal,  inevitable part of aging.   Except that it is not. Frailty affects about seven percent of those over sixty-five and eighteen percent over eighty, more or less, depending on how you count.1 The majority of older adults does not become frail, some even remaining quite robust.

What exactly is frailty? Frailty is a state of depleted reserves and defenses, resulting in heightened vulnerability. Frail individuals succumb to illness that younger or more robust individuals fight off or rebound from more quickly. It’s as if frail elders simply have worn out earlier than others their age.

No one knows why some older adults become frail. The cumulative, lifetime effects of inflammation or oxidative stress, may be at work. Age-related illnesses, such as diabetes, hypertension, atherosclerosis, and arthritis, may further chip away at physical and mental reserve capacity. Depression may be another culprit.

Numerous studies of older adults suggest that depression and frailty go hand in hand. In my book, Beat Depression to Stay Healthier and Live Longer: A Guide For Older Adults and Their Families, I described the toll depression takes on physical health, aging, and longevity. And I reviewed the evidence that depression causes or worsens many illnesses associated with aging including heart disease, stroke, cancer, diabetes, lung and kidney disease, arthritis, falling and pain. I did not include a chapter on frailty: at the time I wrote the book, I did not feel the scientific evidence for a connection with depression to be sufficiently compelling. But, recently I found a study showing that depression and frailty co-occur almost 90% of the time!1 Clearly depression and frailty overlap and have something in common.

We don’t know whether depression causes frailty or the reverse is true. Or maybe a third process, such as inflammation, leads to both. As I discussed in two different chapters in my book, having depression earlier in life doubles the chance of developing both Parkinson’s disease and Alzheimer’s disease. Could the same be true of frailty?

There are many reasons for people suffering from depression to seek treatment for it. Those who don’t, choosing to endure depression, unwittingly put their health and longevity at risk. We do not yet know whether treatment of depression prevents frailty. But it’s beyond doubt that depression is treatable, at any age. The possibility that treating depression might prevent frailty is one more reason why anyone with depression should get professional help for it.

 

  1. Patrick J. Brown, Steven Roose, Robert Fieo, et.al., “Frailty and Depression in Older Adults: A High-risk Clinical Population”, American Journal of Geriatric Psychiatry 2014; 22 (11): 1083-1095.

 

WE NEED MORE ELDER LAW ATTORNEYS

September 5th, 2016 by Dr. G. Moak

Priority one is the critical shortage of geriatric psychiatrists, but once we do something (we currently are doing nothing; quite the opposite) to increase their ranks, we need to increase the availability of elder law attorneys. I don’t know too many people who say we need more lawyers, but I do; at least those who know something about mental health, aging, and the law.

If you follow this blog, you’ve probably noticed that I don’t usually write about elder law issues. Over the years I’ve noticed that the legal system, doesn’t get mental law as it pertains to Alzheimer’s disease and related disorders very well. Since coming to New Hampshire Hospital, I’ve become more acutely aware of this. The following case is illustrative.

My patient – we’ll call her Doris, but this is not her real name – is sixty years old. She was admitted to the hospital one year ago, after she was found wandering in traffic. The police apprehended her and found her to be disheveled and incoherent. They took her to a local hospital emergency room, where she was calm and alert but absolutely incoherent. She made no sense at all, save a few terse phrases she repeated over and over. Tests were unrevealing. There was no evidence that head injury, infection, drugs, or other physical illnesses could be causing this.   The consulting psychiatrist at the hospital thought she might have schizophrenia, and she was committed to a community psychiatric hospital and transferred shortly thereafter to New Hampshire Hospital, the state psychiatric hospital.

Doris has a complicated history: Long story short, she has frontotemporal dementia, not schizophrenia. How a patient with severe dementia winds up in a state psychiatric hospital raises many other issues, for another day. There is little we can do for her beyond providing total care and supervision in a secure, safe environment and relieving her agitated distress with psychiatric medications.

But this has worked out well, and for the last eleven months Doris has been stable. She paces about ceaselessly, and but for the locked door to our unit, she would wander away. Her only activities besides wandering around are eating and sleeping. She can participate in no activities, even simple sensory stimulation. Doris remains completely mute except for three 1-3-word phrases she utters repeatedly throughout the day. One of these utterances is “No!” She cannot answer even simple yes/no questions (when she says “No!” it is not in response to a question or a request to do something), carry on a conversation, or express any likes, dislikes, or preferences.

It took us one month to decide that she needed long-term care, and that a nursing home with a secure memory care unit would meet her needs and be in her best interest. It took another eleven months to make this happen.   The delays were mostly bureaucratic, and I won’t bore you here with the details. Instead let’s talk about the last delay, which occurred at the hands of the legal system, and brings us to the point of this post.

In order for a nursing home to admit her she needed a guardian. Not a problem. We got one, no problem. Last hurdle cleared? I’m afraid not. We could not find a nursing home with the services she needed. Few had secure memory care units. Even fewer had access to expert geriatric psychiatry consultants to help them take care of her. To be fair, patients with frontotemporal dementia do pose significant challenges for nursing homes. After we exhausted all avenues, we turned to the last remaining option, the state’s specialty psychiatric nursing home.

We made the necessary applications and again waited out the bureaucratic delays. One of these is the requirement for guardians to petition the court for the added authority to admit a ward to this particular nursing home. Usually this is pro forma, so when the guardian filed the necessary motion, we expected quick approval. A hearing was scheduled, and the court appointed an attorney to represent Doris – routine SOP.

Now here’s where things became unreasonable. The court-appointed lawyer came to interview his client, Doris, and, after meeting with her (which means he followed her about the unit while she paced continuously) he somehow decided that she had a clear objection to the proposed transfer. So he filed a motion opposing the guardian’s petition! True, we provide Doris very good care, but that’s beside the point. She’s not consciously aware of it or her options. Not only is she incapable of making an informed choice, she’s completely unaware of the choice. This is obvious to everyone, including family members, except her attorney. How did he decide that he knew his client’s wishes? You don’t have to be a geriatric psychiatrist or a forensic psychiatrist to see that it’s obvious that she does not have the capacity to assist in her own legal representation.

The cynics among you probably think that Doris’s lawyer simply took advantage of what seemed like a no-muss-no-fuss way to rack up billable hours. I don’t think so. I’ve seen this attorney in action before and have had the impression that he takes his role as an officer of the court very seriously and is zealous about his responsibility to represent his clients’ wishes as best he can. Somehow he construed Doris’s limited vocalizations as expressions of her preferences.

Here’s what I think happened. Recall that Doris only utters three phrases, one of which is “No!” If you “lead” this witness properly, you might get what sounds like an emphatic position: “Doris, do you want to leave New Hampshire Hospital”: “No!” “Doris, would you like to be transferred to the psychiatric nursing home?” “No!” Assuming something like this transpired, you have to be very cynical or very naïve to use it as the basis for legal representation. Physicians would not take this for an informed refusal of care, and you would think attorneys would apply similar standards.

You might make the case that, given the adversarial nature of our legal system, that the best thing to do would be to oppose the motion and let the court decide based on the facts established in the courtroom.   Okay, but at what expense?

Because Doris would not know where she was or understand what was going on, and could not sit still and remain quiet while court was in session, and might become agitated, I filed a petition to waive her presence. There clearly seemed no benefit to her to be there. But Doris’s lawyer insisted she come. Three hospital staff members were required to transport her to and from the courthouse and accompany her while she was there. Despite their presence, Doris wandered around while court was in session and approached the bench twice and yelled “No!” at the judge. Fortunately, she did not become physically aggressive. I don’t know how gentle the bailiff would have been with her. And, because the motion was being contested, Doris’s social worker and I also had to be present to testify. Add in court time, and you can appreciate how costly this hearing was.

Even worse, by delaying Doris’s inevitable transfer this legal charade squandered precious hospital resources. Psychiatric beds, especially geriatric psychiatry beds, are in critically short supply in my state. Doris had not needed inpatient psychiatric services in many months, and while we waited to transfer her to a long-term care facility other, mentally ill elders waited for services because there were no open beds on our unit. Many severely psychiatrically ill geriatric patients wait in hospital emergency rooms for days, and sometimes weeks, until a bed opens in our program. Often the get admitted to general adult psychiatry units instead. This is better than languishing in the emergency room, but falls short of the specialty geriatric psychiatry care they need.

These days physicians are exhorted to make clinical decisions not only based on the best interest of their patients but also with an eye toward the conservation of healthcare resources, which is in everyone’s interest. Shouldn’t the legal system bare some of the same stewardship responsibility?

When Doris’s attorney represented to the judge that Doris had expressed a preference not to be transferred I was incredulous: Her lawyer either perjured herself or was incompetent. In Doris’s case, I’m pretty sure it was the latter.

Don’t get me wrong. We need more attorneys who are zealous about protecting their older client’s rights. But they must understand something about geriatric psychiatry. In my experience, some older adults too easily get railroaded into nursing homes before other options are properly explored, because their attorneys do not know the right questions to ask or consultations to seek. Attorneys familiar with aging issues, dementia, and geriatric medicine can prevent this. But lawyers who are familiar with the needs of patients with severe dementia can ensure their clients’ rights and interests are protected and respected while avoiding unnecessary legal delays and costs that don’t serve their clients well and logjam the healthcare system.

Gary S. Moak, M.D

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

Depression and Accelerated Aging

June 16th, 2016 by Dr. G. Moak

My book, Beat Depression to Stay Healthier and Live Longer: A Guide for Older Adults and Their Families, deals with the toll depression takes on physical health and functional robustness. While most of the chapters explain how depression increases the occurrence and severity of particular disease (stroke, cancer, diabetes, to name a few), in Chapter 5, I alert readers to the truly alarming possibility that depression might work by accelerating the aging process.

Depression is a common problem among older adults. It is the second leading cause of disability, worldwide, among people of all ages. The emotional and financial burdens depression imposes on individuals and society are staggering. If depression truly accelerates the aging process, then it is even a greater public health problem them we realized.

What evidence is there that depression accelerates the aging process? The answer, in a word, is telomeres. Aging researchers have been zeroing in on them.

Telomeres are molecular caps on the DNA in chromosomes, the substance in cells that contains a person’s genes. You can think of telomeres like aglets, the caps on the ends of shoelaces that prevent unraveling. In like fashion, telomeres protect DNA from damage during cell division.

Scientists can measure the length of telomeres. Each time a cell divides its telomeres shorten. Aging researchers consider telomere length to be a measure of age, because cells divide only so many times in their lifespan. When a cell’s telomeres shorten below a critical length, the cell becomes susceptible to breakdown, illness, and death. As more cells succumb to this fate, organs begin to show signs of aging and become prone to disease. You can imagine where this ends up. Essentially, when your telomeres’ numbers are “up”, so’s yours. The more cumulative depression a person has throughout life, the shorter their telomeres. By observing the average degree to which depression shortens telomeres, scientists have been able to estimate that it ages people five years or more.

A new study*, from the Netherlands Study of Depression and Anxiety, provides good and bad news. Previously, research on depression and telomeres had been limited to measurements at one time. In the Netherlands study, researchers, for the first time, followed the effect depression had on telomere length over time, six-years, to be exact. And they did it with a very large number of patients. The results from this first-of-its-kind study are a good news/bad news story.

First the bad news: This study confirmed that depression does shorten telomeres to a degree corresponding to four to five years of life expectancy. Worse yet, the Danish scientists found that this effect didn’t go away even among those whose depression fully remitted. Six years later their telomeres were still short even though they had been well.  Depression seems to leave some type of scar on the brain.

That’s the bad news. But there’s a silver lining, of sorts, in this dark cloud. True, depression shortens telomeres, and this doesn’t go away even if depression does… and stays away. But depression doesn’t cause telomeres to continue to shorten any faster than they do in people who have never had depressed. In other words, depression may advance the aging clock, akin to turning the time ahead for daylight savings time; but it doesn’t make the clock run any faster. You keep getting older at the same rate, as long as you don’t get depressed again.

There are many reasons for adults, of all ages, to take depression seriously and get effective treatment for it. For those who do not want to be old before their time, this may be the most compelling.

 

* JE Verhoe, Patricia van Oppen, Dora Revesz, Owen M. Wolkowitz, and Brenda W.J.H. Pennix, “Depressive and Anxidty Disorders Showing robust, but Non-Dynamic, 6-Year Longitudinal Association With Short Leukocyte Telomere Length,” American Journal of Psychiatry, 2016; 173: 617-624.

ELDERLY PATIENTS DYING OF DEPRESSION IN HOSPICE: PSYCHIATRIC PHYSICIAN ASSISTED SUICIDE?

May 19th, 2016 by Dr. G. Moak

In a study recently published online ahead of print in the Journal of the American Medical Association investigators described the application of physician assisted suicide (PAS) for psychiatric reasons in the Netherlands. That’s right – psychiatric reasons! Apparently the Dutch allow PAS for intractable mental and emotional suffering due to mental disorders.

In the United States, PAS remains highly controversial. The morally acceptable place of PAS has been, at least so far, generally limited to the compassionate relief of intractable, unbearable pain associated with terminal or incurable illness.

To the extent that PAS has been viewed to be a reasonable option for psychiatric reasons this has been in connection with longstanding, severe, treatment-resistant depression. In fact, this was the case in 41 percent of the 66 cases reviewed in the JAMA study. The remaining 25 patients received PAS for anxiety, PTSD, schizophrenia, prolonged grief, and substance abuse. Two persons had PAS for “incipient dementia”! Assuming they had good reason to believe that progression to full-blown dementia was inevitable, this means they chose to die rather than live with dementia.

In have reservations about PAS, in general, and I find the idea of applying it for suffering related to psychiatric disorders quite problematic. I was most disturbed to learn that many of the Dutch patients received PAS from a mobile, end-of-life clinic. Really? I’m fairly progressive about palliative care (although I remain skeptical about the adequacy of safeguards), but wow: The Dutch have a “deathmobile”.

In an accompanying editorial to the JAMA study, Paul Appelbaum, M.D., raised concerns about PAS for psychiatric disorders. Most obvious among these is that undue hopelessness, nihilism about life and treatment, and the desire to die all can be intrinsic features of depression. Patients who receive effective treatment, and respond, often give up their wish to die and feel glad to go on living. Appelbaum presciently asks, “Will psychiatrists conclude from the legalization of assisted death that it is acceptable to give up on treating some patients? If so, how far will that belief spread?” Let me tell you. It already has spread to hospice care for the frail elderly.

CASE ONE   An eighty-four-year-old man with lifelong recurrent depression had been chronically depressed for three years despite several, reasonable attempts by his primary care physician.   During this period, he also developed Parkinsonism and dementia, both of which remained mild. Throughout the course of his depressive illness he regularly talked about feeling useless and wishing to die. He became increasingly withdrawn and inactive, and this brought on deconditioning, frailty, weight loss and cachexia.

The patient’s family’s concern grew to alarm and panic, and they arranged for an evaluation by a geriatric psychiatrist. The patient had failed to respond to several antidepressants, and had been unable to tolerate several others. Family members were hoping for a “magic pill”. Unfortunately, there was no magic for this poor soul, but the geriatric psychiatrist thought trials of tricyclic antidepressants, Monoamine oxidase inhibitors or electroconvulsive therapy were reasonable, and offered some hope to reverse the patient’s inexorable decline. But the patient refused all further treatment, and his family was unwilling to impose any of the options against his will. Deciding that he was now in the end stage of dementia, they arranged for transfer to a nursing facility, where he also did not want to go, and hospice care was initiated. Two months later he died.

Hospice services are increasingly delivered to patients with end-stage dementia. In my mind, the practice is fraught with problems. But more about that in a subsequent post. This patient did have dementia, but it was mild. He was not dying of dementia; he was dying of depression. He’d become “end stage” because depression had been allowed to go untreated. This would not have been allowed to happen to a younger patient.

CASE TWO – An eighty-eight-year-old woman had recurrent major depressive disorder since menopause. The most recent episode had been especially severe and difficult to treat, and she had required psychiatric hospitalization. Eventually she responded to treatment, but her recovery was complicated by acute cholecystitis, C. Difficile infection, congestive heart failure, and respiratory insufficiency. She went from the psychiatric inpatient unit to the intensive care unit, and, from there, a rehabilitation program in a nursing facility.

Once in rehab, she remained medically stable, and was expected to recover fully. However, the stress of the ordeal triggered a relapse of depression. She became hopeless, pessimistic, and negative. She insisted, “Enough is enough”, and expressed a wish to be allowed to die. And she didn’t wait to hear what her doctors had to say: she stopped eating, and refused to take any medications.

A consulting psychiatrist evaluated her and confirmed that she, in fact, once again, was severely depressed. Moreover, the psychiatrist confirmed that this was the basis for the patient’s refusal to eat or take medications. After discussion with her rehab team, two courses were recommended to the patient’s family. The first was placement of a feeding tube, which would allow the patient to be nourished and given medications, including antidepressants. The second was ECT. Both options involved treating the patient against her will. The family wanted to consider ECT. But they ruled out a feeding tube because the patient had specified that she did not want this in her advance directives.

To their credit, the patient’s family wanted to abide by her wishes, as she had spelled them out. Unfortunately, they wrongly applied her express intentions out of the context meant by the patient. Her advance directive stated that she did not wish to be kept alive by artificial feeding or be put on a breathing machine in the event she suffered from a life-threatening, catastrophic illness from which there was no hope of recovery.

While the best course of action was being considered, the patient became dehydrated and developed pneumonia with delirium. She was transferred back to the hospital and admitted to the ICU. This time she had a different hospitalist (hospital doctor) who did not know her or her family. This doctor saw a confused patient of advanced age who was critically sick and who had well-spelled-out advance directives. Many patients fitting this description have dementia, and it has become acceptable, and common practice to withhold very invasive, aggressive ICU care (imagine a bed-ridden person with tubes in every opening and hooked up to numerous machines including a mechanical ventilator) in favor of providing only comfort measures and allowing a “natural death” to occur. Often this is the best thing to do. But the hospitalist did not know the patient before she had become critically ill, and did not realize how vitally alive she had been prior to the depressive episode which triggered her current decline. In the urgency of the ICU, he counseled against aggressive, life-sustaining treatment and recommended transfer to a hospice for end-of-life care. The family agreed. Two weeks later she died.

What do these two cases show us? In American medicine, some very old patients who are critically ill are allowed to forego treatment that might prolong their lives when further care seems futile. For those with severe dementia, terminal illness, or persistent delirium, when further treatment is futile, this can be humane and compassionate. But at the same time, maybe the practice has become so routine and commonplace that we have become inured to it. It takes training, experience, and expertise to assess the mental state, intentions, and decision-making ability of critically sick elderly patients who wish to die. The sad reality is that few clinicians in our healthcare system have geriatric expertise, and it’s become too easy for those without it to allow patients who are depressed, and refusing treatment, to die.

Scott Y.H. Kim, Raymond G. DeVries, John R. Peteet, “Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014”, JAMA Psychiatry 2016; 73(4): 362-368.
Paul S. Appelbaum, “Physician-Assisted Death for Patients With Mental Disorders – Reasons for Concern”, JAMA Psychiatry 2016; 73(4): 325-326.