Are you positive you know which diagnoses should be included in M1010/M1016?

I’ve been sitting here looking over the new guidance for M1016 and know this is a “hot topic” right now so wanted to pass it along.  Before discussing M1016, we must first talk about M1010.  Both of these items are used in risk adjustment and selection of codes for both, M1010 (Inpatient Diagnoses) and M1016 (Medical or treatment regimen change) are for those diagnoses that were actively treated or required change within past 14 days.

Look first at M1010: when identifying which diagnoses should be assigned to M1010 (inpatient diagnoses), you should look closely at hospital documentation.  Only those diagnoses that were actively receiving treatment in an inpatient facility within the past 14 days will be included.  Actively treated should be defined as receiving something MORE than the regularly scheduled medications and treatments for the condition.  If a diagnosis was NOT treated during an inpatient admission, it should not be listed.  For example: the patient was admitted for uncontrolled diabetes, but the patient also has a diagnosis of hypertension and depression, which they received their regularly scheduled medications for.  The only diagnosis actively treated was uncontrolled diabetes; the others should not be listed in M1010.  The conditions listed in M1010 also may include those where there has been a change in specific treatment parameters or a change in health services (i.e. the patient will be receiving dialysis three times a week instead of four times a week).

Now let’s look at M1016: the diagnoses assigned to M1016 should be new conditions or existing conditions that have exacerbated within the last 14 days. “Medical regimen change” is not limited to changes in medications.  Like M1010, the use of symptoms should be minimized. Diagnoses assigned to M1016 should be coded to the highest level of specificity and conditions in M1016 may or may not be the same as those in M1010 or M1020/M1022.

The issue of assigning “improved” conditions in M1016 was addressed by CMS in Category 4 of the OASIs C1/ICD-9 consolidated Q&As (June 2014). The Q&A states:

If at any time in the last 14 days the patient requires a medical or treatment regimen change due to development of a new condition or lack of improvement or worsening of an existing condition, the diagnosis should be reported in M1016, EVEN if the condition also showed improvement or stabilization during that time, or it is improved at the time of the SOC/ROC.”

The CMS response regarding the assignment of improved conditions in M1016 means that it is acceptable to code these conditions in M1016 when the condition still exists and it is relevant to the care of the patient. Review this phrase in the guidance: “…the diagnosis should be reported in M1016, even if the condition also showed improvement or stabilization during that time, or is improved at the time of the SOC/ROC.

Up ↑

%d bloggers like this: