ICD-10-CM Impact on PDPMICD-10-CM Impact on PDPM POST TEST ANSWERS 1. The care team needs to identify and sequence all codes in I8000 including first-listed primary reason for admission

ICD-10-CM Impact on PDPM

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POST TEST

1. The care team needs to identify and sequence all codes in I8000 including first-listed primary reason

for admission under PDPM. a. True b. False

2. Hospital Procedure Codes (ICD-10-PCS) cannot change the PDPM clinical category from the default

clinical category. a. True b. False

3. You must use the decimal after the 3rd character of the ICD-10-CM code when searching by

code in the CMS clinical mappings. a. True b. False

4. PT, OT, and SLP PDPM Components are affected by ICD-10-CM coding?

a. True b. False

5. Unspecified laterality codes result in Return to Provider under PDPM.

a. True b. False



POST TEST ANSWERS

1. The care team needs to identify and sequence all codes in I8000 including first-listed primary reason for admission under PDPM.

c. True d. False

2. Hospital Procedure Codes (ICD-10-PCS) cannot change the PDPM clinical category from the default

clinical category. c. True d. False

3. You must use the decimal after the 3rd character of the ICD-10-CM code when searching by

code in the CMS clinical mappings. a. True b. False

4. PT, OT, and SLP PDPM Components are affected by ICD-10-CM coding?

a. True b. False

5. Unspecified laterality codes result in Return to Provider under PDPM.

a. True b. False


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1


Understand PDPM & Importance of ICD-10-CM Coding Accuracy

For the first time ever, SNFs are now going to be reimbursed in large part

based on Diagnosis!

Hospitals have been paid by Diagnosis for years.

2



Definitions

• PDPM – Patient-Driven Payment Model • Component of rate – portion of total PDPM payment• CMG – Case Mix Group• CMI – Case Mix Index assigned a CMG• IPA – Interim Payment Assessment • PT – Physical Therapy• OT – Occupational Therapy• SLP – Speech/language Pathologist • NTA- Non-Therapy Ancillary • Tapering/Variable Payment Adjustment – Method to

decrease daily payment over the course of a Part A stay 3


PDPM Overview

• PDPM will have six components, 5 of which are Case-mix adjusted: – PT

– OT

– SLP

• Index Combining-Combines dollar amounts for each component per day.

• One MDS for entire stay – one exception• Rate per day will change due to variable/tapering rates

for PT, OT, and NTA. 4

– Nursing

– Non-Therapy Ancillary (NTA)

– Non-Case Mix Rate



• Every resident is assigned a CMG for each Payment Component (except Non-Case Mix Payment is fixed)

5


Overview of ComponentsPT - 16 OT-16 SLP -12 Nursing-25 NTA - 6

• Primary reason for SNF care via MDS Section I –I0020B

• Functional status –Section GG

• Primary reason for SNF care via MDS Section I –I0020B

• Functional status –Section GG

• Primary reason for SNF care is acute Neurologic MDS Section I -I0020B

• SLP-comorbidities –Section I

• Cognitive

• Presence of swallowing disorder or mechanically altered diet

• Clinical information from SNF stay

• Functional status - GG

• Extensive services received

• Presence of depression

• Restorative nursing services received

• Comorbidities present –Section I

• Extensive services received

• Payment decreases after Day 20

• Payment decreases after Day 20

No variable rate No variable Rate

• Payment decreases after Day 3 6



ICD-10-CM Impact

• Final Rule stated the Primary Reason for Admission will be required to be listed first under I8000 for Clinical Category

• PDPM update document states: New MDS Item: Section I: SNF Primary Diagnosis To capture the patient’s primary diagnosis, which is used to classify the patient into a PDPM clinical category, CMS to add Item I0020B, which allows providers to report, using an ICD-10- CM code, the patient’s primary SNF diagnosis.– No further info; may need to match I8000 first listed.

7


CMS Update

New MDS Item: Section I: SNF Primary Diagnosis • To capture the patient’s primary diagnosis, which is

used to classify the patient into a PDPM clinical category, CMS added Item I0200B, which allows providers to report, using an ICD-10-CM code, the patient’s primary SNF diagnosis. The item will ask “What is the main reason this person is being admitted to the SNF?” Item I0200B will be coded when Item I0020 is coded as any response 1 – 13.

8



New Item Set

9

I0020B New

If mark 14, then I0020A may drive Clinical Category


MDS Section I8000

10

May suggest to match I0020B to determine Clinical category for PDPM – OT, PT, SLP

Code all Comorbidities that apply for NTA and SLP if not listed above in A.

New Item Set I0020B will be used to determine Clinical Category



Hospital Surgical Procedures

• Hospital Surgery Procedures will be used to augment (support) the I0020B ICD-10 code used for Primary Reason for Admission.

• If the resident may have had qualifying surgical procedure ICD-10-PCS code as indicated by column D in clinical mappings, it will direct you to either the “Ortho Surgery” Tab or “Non-Ortho” Surgery tab.

• If the resident received a qualifying ICD-10-PCS code, then it can change the PDPM clinical category rather than the default clinical category.

• CMS states they will not require actual procedure codes on MDS but rather a check box format. 11


Issues impacting Implementation

• CMS is adding new items in Section J of the MDS. These items are Items J2100 – J5000.

• There will be a list of surgical procedures; check any if apply when needed to support Primary Reason for Admission Clinical Code per mapping.

12



Hospital Surgical Procedures

• Once the Clinical Diagnosis is determined; it will indicate on CMS Clinical Mapping spreadsheet if a adjunct Hospital Procedure would need to be indicated on MDS.

• Evaluate now what hospital is providing in discharge summary regarding type of surgical procedure and whether adequate to perform search when needed on Clinical Mapping spreadsheets with or without ICD-10-PCS code.

13


MDS Changes for Surgical Procedure Codes

14

These items will be used, in conjunction with the diagnosis code captured in I0020B, to classify patients into the PT and OT case-mix classification groups for PDPM. Similar to the active diagnoses captured in Section I, these Section J items will be in the form of check-boxes.



MDS Changes for Surgical Procedure Codes

15


PDPM Components

16



Nursing Component

PDPM

Every resident is assigned a Nursing CMG

No ICD-10 Codes impact Nursing Component of the rate

17


Therapy CategoriesPT & OT

Diagnosis in I0020B affects PT/OT Component of the rate

18



PT and OT ComponentsPDPM

Every resident is assigned a PT CMG and an OT CMG (which is the same CMG) even if no therapy is provided.

While the Case-Mix Group is the same, the CMI/payment will be different.

19


PT/OT Components

• Clinical reason for SNF stay (Primary Reason for Admission) to SNF Coded – First Listed Diagnosis code in I8000– falls into ONE of these categories

– Joint Replacement or Spinal Surgery

– Other Orthopedic

– Non-Orthopedic Surgery & Acute Neurologic

– Medical ManagementSee Mapping spreadsheet for ICD-10-CM Details

20



PT/OT ComponentsPDPM Clinical Category Collapsed PT and OT

Clinical Category

Major Joint Replacement or Spinal Surgery


Non-Orthopedic Surgery Non-Orthopedic Surgery and Acute NeurologicAcute Neurologic

Non-Surgical Orthopedic/Musculoskeletal

Other OrthopedicOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Medical Management

Medical Management

Acute Infections

Cancer

Pulmonary

Cardiovascular and Coagulations21


PT and OT Case-mix Classification Groups

Clinical Category

Section GG

Function Score

PT OT Case-mix

Group

PT Case-mix

Index

OT Case-mix

Index

Major Joint Replacement or Spinal Surgery 0-5 TA 1.53 1.49

Major Joint Replacement or Spinal Surgery 6-9 TB 1.69 1.63

Major Joint Replacement or Spinal Surgery 10-23 TC 1.88 1.68

Major Joint Replacement or Spinal Surgery 24 TD 1.92 1.53

Other Orthopedic 0-5 TE 1.42 1.41

Other Orthopedic 6-9 TF 1.61 1.59

Other Orthopedic 10-23 TG 1.67 1.64

Other Orthopedic 24 TH 1.16 1.15

Medical Management 0-5 TI 1.13 1.17

Medical Management 6-9 TJ 1.42 1.44

Medical Management 10-23 TK 1.52 1.54

Medical Management 24 TL 1.09 1.1122



PT and OT Case-mix Classification Groups

Clinical CategorySection GG

Function Score

PT OT Case-mix

Group

PT Case-mix

Index

OT Case-mix Index

Non-Orthopedic Surgery and Acute Neurologic

0-5 TM 1.27 1.30


6-9 TN 1.48 1.49


10-23 TO 1.55 1.55


24 TP 1.08 1.09

23


SLP Component

PDPM

Every resident is assigned a SLP

CMG even if no therapy is provided

I0020B, I8000 and other MDS items affect SLP Component of rate

24



PDPM SLP Component

• Each resident will be placed into one of 12 SLP classifications, based on:– Clinical Categories – based on I0020B

• Acute neurologic and non-neurologic

– SLP-related Comorbidity – One or more coded in Section I

– Mild to Severe Cognitive Impairment – yes or no

– The presence of a Swallowing Disorder or Mechanically Altered Diet - both, either or neither

25


PDPM SLP Component

Clinical reason for SNF stay (Primary Reason for Admission) Acute Neurologic or Non-Neurologic

Will be determined by I0020B

See ICD-10-CM Mapping to Clinical Categories spreadsheet

26



PDPM SLP Component

Primary Diagnosis Clinical Category SLP Clinical Category

Major Joint Replacement or Spinal Surgery Non-Neurologic

Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Non-Neurologic

Non-Orthopedic Surgery Non-Neurologic

Acute Infections Non-Neurologic

Cardiovascular and Coagulations Non-Neurologic

Pulmonary Non-Neurologic

Non-Surgical Orthopedic/Musculoskeletal Non-Neurologic

Acute Neurologic Acute Neurologic

Cancer Non-Neurologic

Medical Management Non-Neurologic 27


SLP Component

• SLP Comorbidities (MDS) – any one coded = Yes – I4300 Aphasia– I4500 CVA, TIA, or Stroke– I4900 Hemiplegia or Hemiparesis– I5500 Traumatic Brain Injury– I8000 Laryngeal Cancer– I8000 Apraxia– I8000 Dysphagia– I8000 ALS– I8000 Oral Cancers– I8000 Speech and Language Deficits– O0100E2 Tracheostomy Care While a Resident– O0100F2 Ventilator or Respirator While a Resident

28

List all that apply in I8000 after First Listed Diagnosis

Check all that apply



Example of SLP I8000 Comorbidities (Not Complete List)

SLP-Related Comorbidity ICD-10-CM Code

Section I8000 Description

ALS G12.21 Amyotrophic lateral sclerosis

Apraxia I69.990 Apraxia following unspecified cerebrovascular disease

Dysphagia I69.991 Dysphagia following unspecified cerebrovascular disease

Laryngeal Cancer C32.0 Malignant neoplasm of glottis

Laryngeal Cancer C32.1 Malignant neoplasm of supraglottis

Laryngeal Cancer C32.2 Malignant neoplasm of subglottis

Laryngeal Cancer C32.3 Malignant neoplasm of laryngeal cartilage

Laryngeal Cancer C32.8 Malignant neoplasm of other specified sites of larynx

Laryngeal Cancer C32.9 Malignant neoplasm of larynx, unspecified

Oral Cancers C00.0 Malignant neoplasm of external upper lip

Oral Cancers C00.1 Malignant neoplasm of external lower lip

Oral Cancers C00.3 Malignant neoplasm of upper lip, inner aspect 29


SLP Case-Mix Classification GroupsPresence of Acute Neuro Condition, SLP-Related Comorbidity, or Cognitive Impairment – Mild, Moderate, or Severe

Mechanically Altered Diet or Swallowing Disorder

SLP Case-Mix Group

SLP Case-Mix Index

None Neither SA 0.68

None Either SB 1.82

None Both SC 2.66

Any one Neither SD 1.46

Any one Either SE 2.33

Any one Both SF 2.97

Any two Neither SG 2.04

Any two Either SH 2.85

Any two Both SI 3.51

All three Neither SJ 2.98

All three Either SK 3.69

All three Both SL 4.19

30



Non-Therapy Ancillary Component

PDPM

Every resident is assigned a NTA CMG

I8000 ICD-10 codes and other MDS items affect NTA Component of

rate31


NTA Component

• Based on clinical conditions, each qualifying conditions is assigned points.

• Total points are calculated then is assigned to one of 6 NTA CMGs

• Variable NTA per diem case mix adjustment– Day 1-3 NTA per diem will be triple the per diem

for days 4-100 of stay.

32



Conditions/Extensive Services for NTA Classification Points

33

Condition/Extensive Services MDS Item Points

HIV/AIDS N/A (SNF Claim)

8

Parenteral IV Feeding: Level High K0510A2 & K0710A2=3

7

Special Treatments/Programs: Intravenous Medication Post-admit Code

O0100H2 5

Special Treatments/Programs: Ventilator or RespiratorPost-admit Code

O0100F2 4

Parenteral IV Feeding: Level Low K0510A2& K0710A2=2K0710B2=2

3

Lung Transplant Status I8000 3

Special Treatments/Programs: Transfusion Post-admit Code O0100I2 2

Major Organ Transplant Status, Except Lung I8000 2

Active Diagnoses: Multiple Sclerosis Code I5200 2

Opportunistic Infections I8000 2


Conditions/Extensive Services for NTA Classification

34


Active Diagnoses: Asthma, COPD, Chronic Lung Disease Code I6200 2

Bone/Joint/Muscle Infections/Necrosis – Except: Aseptic Necrosis of Bone

I8000 2

Chronic Myeloid Leukemia I8000 2

Wound Infection Code I2500 2

Active Diagnoses: Diabetes Mellitus (DM) Code I2900 2

Endocarditis I8000 1

Immune Disorders I8000 1

End-Stage Liver Disease I8000 1

Other Foot Skin Problems: Diabetic Foot Ulcer Code M1040B 1

Narcolepsy and Cataplexy I8000 1

Cystic Fibrosis I8000 1

Special Treatments/Programs: Tracheostomy Care Post-admit Code

O0100E2 1




35


Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code I1700 1

Special Treatments/Programs: Isolation Post-admit Code O0100M2 1

Specified Hereditary Metabolic/Immune Disorders I8000 1

Morbid Obesity I8000 1

Special Treatments/Programs: Radiation Post-admit Code O0100B2 1

Highest Stage of Unhealed Pressure Ulcer – Stage 4 M0300X1 1

Psoriatic Arthropathy and Systemic Sclerosis I8000 1

Chronic Pancreatitis I8000 1

Proliferative Diabetic Retinopathy and Vitreous Hemorrhage I8000 1

Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code

M1040A, M1040B, M1040C

1

Complications of Specified Implanted Device or Graft I8000 1

Bladder and Bowel Appliances: Intermittent catheterization H0100D 1

Inflammatory Bowel Disease I8000 1



36


Aseptic Necrosis of Bone I8000 1

Special Treatments/Programs: Suctioning Post-admit Code O0100D2 1

Cardio-Respiratory Failure and Shock I8000 1

Myelodyplastic Syndromes and Myelofibrosis I8000 1

Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies

I8000 1

Diabetic Retinopathy – Except: Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

I8000 1

Nutritional Approaches While a Resident: Feeding Tube K0510B2 1

Severe Skin Burn or Condition I8000 1

Intractable Epilepsy I8000 1

Active Diagnoses: Malnutrition Code I5600 1

Disorders of Immunity – Except: RxCC97: Immune Disorders I8000 1

Cirrhosis of Liver I8000 1

Bladder and Bowel Appliances: Ostomy H0100C 1

Respiratory Arrest I8000 1

Pulmonary Fibrosis and Other Chronic Lung Disorders I8000 1



NTA Case Mix Classification Groups

NTA Score Range

NTA Group NTA Case Mix Index

12+ NA 3.25

9-11 NB 2.53

6-8 NC 1.85

3-5 ND 1.34

1-2 NE 0.96

0 NF 0.7237


NTA Comorbidities

• ICD-10-CM diagnoses impact comorbidities for points.

• Section I must be accurate for all comorbidities that apply to resident and supported in medical record – Check all that apply.

• I8000 must include all comorbidity ICD-10 codes. – See PDPM NTA Comorbidities to ICD-10-CM

mapping spreadsheet 38



Comorbidity Codes in I8000

• Be sure to include all comorbidity codes for SLP and NTA in I8000

• Some CVA codes qualify for SLP Comorbidity and some do not – Be sure to include all I69 codes in I8000

39


I69 Codes that Qualify for SLP Comorbidity

• I69.990 Apraxia following unspecified cerebrovascular disease

• I69.991 Dysphagia following unspecified cerebrovascular disease

• I69.928 Speech and Language Deficits, Other speech and language deficits following unspecified cerebrovascular disease

40




• I69.920 Speech and Language Deficits, Aphasia following unspecified cerebrovascular disease

• I69.921 Speech and Language Deficits, Dysphasia following unspecified cerebrovascular disease

• I69.922 Speech and Language Deficits,

Dysarthria following unspecified cerebrovascular disease

41



• I69.923 Speech and Language Deficits, Fluency disorder following unspecified cerebrovascular disease

• I69.928 Speech and Language Deficits, Other speech and language deficits following unspecified cerebrovascular disease

42



Non-Case Mix Component

All residents have the Non-Case Mix Rate applied

No ICD-10 Codes impact CMG

43


How to use CMS ICD-10-CM Clinical Mapping

44



Resources

• CMS ICD-10-CM to PDPM Clinical Categories Mapping spreadsheet– Provided with training

• PDPM NTA mapping of Comorbidities to ICD-10-CM spreadsheet– Provided with training

– https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

45


Clinical Category Mapping

46



47

Steps to Clinical

Mapping


Steps to Clinical Mapping

48



Steps to Clinical Mappings

49


Clinical Mappings – Searching By Drop Down Boxes

50



Mapping S72.001D, Unspecified Hip Fracture

51

Doesn’t come up

in search

box, but can sort from Z

to A



52




53

Column D shows N/A for Qualifying Surgical Procedure so the Clinical Category is the Default = Ortho Surgery (Except Major Joint Replace or

Spinal Surgery)


Return to Provider

• Certain unspecified ICD-10 codes will result in “return to provider” message on the clinical mappings which means that you need to use a more specific code in order to obtain the PDPM clinical category – query the physician if needed

• For example, unspecified laterality codes should not be used and result in “Return to Provider”– S72.009D, Fracture of unspecified part of neck of

unspecified femur, subsequent encounter for closed fracture with routine healing

54



Return to Provider

55


Qualifying ICD-10-PCS Codes

• Most of the 7th character D, Subsequent Encounter, ICD-10 Codes do not qualify for Hospital Surgical Procedure.

• However, the malunion and nonunion (K, M, N, P, Q, R) and sequela (S) fracture 7th character codes do, so be sure to have the correct 7th

character for either subsequent encounter or sequela.

56



Nonunion 7th Character Example

57


Nonunion 7th Character Example

58

S72001K, Fracture of

unspecified part of neck of right

femur, subsequent

encounter for closed fracture with nonunion

May be Eligible for One of the

Two Orthopedic Surgery

Categories



Orthopedic Surgery Tab – ICD-10-PCS Code - 0SPR0JZ

59


Orthopedic Surgery Tab – ICD-10-PCS Code - 0SPR0JZ

60

Now qualifies for Major

Joint Replace or Spinal Surgery instead of Non-

Surg Ortho

***May not be realistic ICD-10-PCS code procedure for this ICD-10 code – just an example. Will have to get PCS codes from

hospital***



Steps for Using NTA Comorbidity Mapping

61


Steps to Use NTA Comorbidities Mapping

PDPM NTA Component Comorbidities to ICD-10-CM Mapping

PurposeTo map comorbidities included in the NTA component of the proposed Patient-Driven Payment Model (PDPM) to ICD-10-CM codes.

Table of Contents

Comorbidity to ICD-10-CM Mapping Cmrbd_to_ICD10_MappingMapping of Comorbidities Included in the Proposed PDPM NTA Component to ICD-10-CM Codes

62



63


NTA Comorbidities Mapping

64



NTA Comorbidity Example – K50012

• K500.12, Crohn’s Disease of small intestine with intestinal obstruction is found on the NTA Comorbidity Mappings and is therefore a qualifying comorbidity diagnosis for the NTA category.

• You can either type in the comorbidity description or specific ICD-10-CM code via the drop down boxes shown on next slides.

65


NTA Comorbidity Mapping Example - K50012

66



NTA Comorbidity Mapping Example - K50012

67


Diagnosis Codes and the MDS

68



Coding

• MDSC should consult with IDT to reach consensus as to which diagnosis category or ICD-10 code should be used.

• Once determined, code in Section I Active Diagnoses and I8000 as applicable.

• Select Primary Reason for Admission for I0020B

• Also include on claim to support skilled stay.

• Include therapy treatment diagnoses.

69


MDS Section I0100 – Active Diagnoses

70



Current Coding Directions

• The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days.

• Review clinical record for current diagnoses including hospital progress notes, transfer documentation, discharge summary, physician orders, etc.

• Ensure that diagnoses in Section I support medications, MDS coding including interviews, and include therapy treatment diagnoses. 71


MDS 3.0 Section I

• Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active.

• Active diagnoses are diagnoses that have a direct relationship to the resident’s current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.

• Do not include conditions that have been resolved, do not affect the resident’s current status or CP.

72




• Diagnosis information captured on the MDS in Section I – Disease Diagnoses

– I8000 (Other Current or More Detailed Diagnoses and ICD-10-CM Codes) available for listing diagnoses with ICD-10-CM codes.

– I0020B will be used to calculate PDPM Clinical Category for OT, PT, SLP.

– Recommend I0020B match first-listed I8000.

– Other diagnoses should support NTA Comorbidities for PDPM.

73


MDS Section I8000

74

May suggest to match I0020B to determine Clinical category for PDPM – OT, PT, SLP

Code all Comorbidities that apply for NTA and SLP if not listed above in A.

New Item Set I0020B will be used to determine Clinical Category




• When physician diagnosis is more specific than item description in I0100-I7900:– Check the more general diagnosis in I0100-I7900– Enter the more detailed diagnosis using the

appropriate ICD-10-CM code in I8000 (MDS 3.0 allows for 5 additional diagnoses)

• Example: Unilateral primary osteoarthritis, right hip– I3700 – Check item I3700 – Arthritis– I8000 – Enter Unilateral primary osteoarthritis, right

hip – Code M16.11.

75


Section I8000 and Aftercare Z Codes

• When Z codes are used, another diagnosis for the related primary medical condition should be checked in items I0100–I7900 or entered in I8000.

• Z codes CAN be primary diagnosis:

• Example: Z47.1 Aftercare for Joint Replacement combined with Z Code for Joint replaced such as Z96.641.

• However, some Z codes are too generic and don’t need to be used:– Z51.89 Encounter of other specified Aftercare

76




• Z Codes can be reported in I8000

• DO NOT report procedure codes in I8000

• Procedure codes are not used in this section

• Results in “fatal error” when submitted to national repository

• Note: Hospital Surgical Procedure Categories will be added to MDS in Section J2100-J5000 which can affect the PDPM clinical category.

77


New MDS Items for NTA Comorbidity

• Adding I1300: Ulcerative Colitis or Crohn’s Disease or Inflammatory Bowel Disease in order to capture these items for NTA Comorbidity for PDPM.

78



IDT Approach to Selecting Primary Reason for Admission Coding

MDS I0020B and should

match I8000 First-Listed

79


Selection of Primary Reason for Admission for PDPM

• Primary Reason for Admission must be entered as an ICD-10 code in I0020B and should match First-Listed I8000 code.

• RAI for Oct. 1, 2019 may provide other directions, in the meantime, continue to use current claims processing guidelines for selecting

Principal/Primary First-Listed Diagnosis for Admission/Encounter for the claim.

80




• If two different diagnoses equally meet the definition of primary reason for admission/principal diagnosis consider CMG in your selection.

• Remember to follow coding convention rules

• For example, if resident has hip replacement due to a hip fracture, this must be coded as a hip fracture NOT replacement as far as I0020B, I8000 First-Listed and on the claim (FL 67/69).

81


Selection of Primary Reason for Admission Example

Ms. K is a 67-year-old female with a history of Alzheimer’s dementia and diabetes who is admitted after a stroke. The diagnosis of stroke, as well as the history of Alzheimer’s dementia and diabetes, is documented in Ms. K’s H&P by the admitting MD. What would you code in I0020B and First-Listed I8000 as the primary reason for admission? Alzheimer’s dementia, diabetes or Stroke?

82



Selection of Primary Reason for Admission Answer:

Answer:

Stroke

83


PDPM Components

• The new I0020B will drive all three therapy component CMG assignments.

– Only Acute Neurologic will impact SLP Component

• Other diagnosis in I8000 could impact comorbidity component of SLP and NTA.

• Recommend first listed code in I0020B & I8000 be Admitting/Principal (FL 69/67) on claim for PDPM.

– Include comorbidities codes when applies 84



Consider Admission Processes

85

Pre-Admission

• Hospital Visits to obtain full picture of clinical needs • Discharge summary will provide diagnoses • Surgery information from hospital is new and critical if

needed via Clinical Mapping

Admission

• 24/48 hour Touch Point– IDT reviews clinical picture to identify any additional information needed to ensure all diagnosis/comorbidities are identified

• Initial goal setting with resident/family• Baseline Care Plan

7-day Check

• IDT reviews diagnoses and determines Primary Diagnosis for I0020B & I8000 prior to submission of MDS

• Resident goals confirmed and clinical approaches to achieve goals finalized



1. Within 24 to 48 hours identify ALL CURRENT diagnoses

– Ensure you are identifying accurate, specific code within 48 hours

– Seek additional information when needed

2. IDT to review all pertinent diagnoses - Many Diagnoses will be obvious for Primary Reason for Admission:

1. Stroke

2. Hip Fracture

3. Hip/Knee Replacement

86




3. By day 7, IDT to determine, finalize selection of Primary Diagnosis for coding in I0020B & I8000

– If not sure which of the identified ICD-10 codes achieves the highest CMG, then run diagnosis through the Clinical Mapping

– Pick ICD-10 codes with highest impact on CMG from Clinical Mapping

4. Next list all other pertinent Diagnoses in I8000 to support NTA and/or SLP comorbidities

87



5. Medical Diagnosis List created by day 7 in priority order for claim• Suggest I0020B & I8000 be listed first

• List codes that support:

Skilled Services

NTA comorbidity points

SLP comorbidities

• Include therapy treatment diagnoses

88



PDPM Summary

• Team work together to determine primary reason for admission, select, then list first in Section I8000 for purposes of practice.

• Section I0020 and I0020A will continue to be used for Quality Measures but not for PDPM.

• Section I0020 and I0020A are Primary Reason for Admission which have specific RAI directions and groupings designed for Quality Measures.

89


One More Thing

• While selecting diagnosis is a team process, who will be the expert in your facility?

• Ensure at least one copy of a current ICD-10-CM Coding book –updated annually October 1.

• Consider intensive training - ICD-10 Coder Certification for identified internal expert.

• Study CMS Clinical Mapping spreadsheets. Ensure you are using latest versions on website.

• Look for Hospital Surgery Diagnosis to determine what is provided now and work with hospital to obtain correct ICD-10-PCS code.

• Evaluate and improve communication about diagnoses upon admission. 90



Selection of Principal and Admitting Diagnosis for

Claim

91


Principal – First Listed Diagnosis for Claim

• Per Medicare Claims Processing Manual

– The Principal Diagnosis is defined as the condition established after study to be chiefly responsible for the admission.

– SNFs enter the ICD-CM code for the principal diagnosis in form locator (FL 67) on UB-04.

– The code must be the full ICD-CM diagnosis code, including all seven characters (for ICD-10)

• RAI for Oct 1, 2019 may provide other directions, in the meantime, continue to use current claims processing guidelines. 92



Principal and Admitting Diagnosis UB04 Fields

• Form Locator 67: Principal Diagnosis–The condition established after study to be chiefly responsible for the admission.

• Form Locator 69: Admitting Diagnosis—The condition identified at the time of admission requiring hospitalization. (inpatient treatment)

• Form Locators 67A – 67Q: Additional Diagnoses to support the skilled care provided.

93


94

Diagnoses Go Here



UB-04 Diagnosis Fields

95


Diagnosis Codes and the UB-04

• For Part A residents: – Create a list of ICD-10-CM diagnoses and codes upon

admission, readmission and as needed (condition changes, MDS schedule, billing cycle)

– Medical Records, Accounting, Nursing and Therapy Services review diagnosis codes as applicable

– Discuss diagnoses in Medicare or other appropriate meetings to assist in determining final diagnosis sequencing

– TRIPLE CHECK Prior to billing each month

96



AHIMA Guidelines for LTC

• AHIMA - American Health Information Management Association

• Is a professional organization that promotes the business and clinical uses of electronic and paper based medical information.

• Provides several certifications and certification exam preparation.

• Publish, ICD-10-CM Coding Guidance for Long-Term Care Facilities

97


LTC GuidelinesRehabilitation and/or Follow-up Care • Coding Acute Diagnoses: An acute condition treated at

the hospital that requires follow-up or ongoing monitoring should be coded for the Post Acute Stay with the acute diagnosis code as long as the condition persists and require follow-up care.

• Coding Resolved Acute Diagnoses: Codes for the acute medical condition treated and resolved in the hospital are assigned and reported by the hospital (i.e., cholecystitis, abdominal aortic aneurysm) but not necessarily coded or reported in the Post Acute facility.– In these instances a Z-Code may be appropriate.

98



Principal and Admitting Dx

• Initial Admission: Principal and Admitting Dx will be the same; could match I0020B and I8000 First-listed under PDPM in the future.

• Continued Stay: – Principal Diagnosis becomes the reason for the

continued stay.

– Admitting is the reason for any change in plan of care (Part B therapy) OR for admission to acute care

• Admitting Diagnosis on claim

99


Initial Admission Example

• A resident who has Parkinson’s Disease was initially admitted to a LTC facility to receive physical and occupational therapy services due to aftercare for a healing right hip fracture.

• Upon initial admission, the following codes would be reported in ICD-10-CM:

• Primary and Admitting - S72.001D Fracture of unspecified part of neck of right femur with routine healing is coded at FL 67 AND FL 69.

• Second Sequenced: G20 Parkinson's disease (FL 67A)100



Initial Admission Followed by Continued Stay

The fracture heals, rehabilitation is completed and the resident continues to reside at the facility. • Code S72.001D is resolved and documented

(usually at discontinuation of Medicare Part A stay).

• For the continued stay, (regardless of payer), code G20, Parkinson's disease, becomes the principal/primary diagnosis (reason for continued stay) (FL 67)

101


Continued Stay Followed by Hospital Stay

• A year later the resident is hospitalized for treatment of pneumonia and returns to the nursing facility with an order for physical/occupational therapies to address a functional decline and for antibiotics.

For the purposes of the UB-04

• FL 67: Principal/Primary Diagnosis remains the reason for continued stay: G20, Parkinson's disease

• FL 67A J18.9, Pneumonia would follow as the second diagnosis.

• FL 69 Admitting Diagnosis would be J18.9, Pneumonia, unspecified organism as the reason for hospitalization. 102



Coding For Continued Stay

• The newly diagnosed condition (FL 67A) will be listed after the principal diagnosis (FL 67) to reflect new conditions that affect the resident.

• Applies to both Part A and Part B.

• The principal diagnosis may or may not be the reason for Medicare skilled services.

• We are awaiting further direction as to whether I0020B and I8000 will need to correspond with principal (FL 67) and/or admitting diagnosis (FL 69) and also for return/readmit situations.

103


Therapy Primary/Medical Diagnosis

• According to Medicare Program Integrity Manual, the primary or medical diagnosis is the reason for therapy services.

• Therapy POT for new Medicare Part A stays require the medical reason to support the therapy services as documented by the physician or qualified practitioner.

• This medical diagnosis may NOT be the same diagnosis as the reason for continued stay (principal/primary/first-listed) diagnosis.

104



Therapy Primary/Medical Diagnosis Continued Stay Example

• A patient with Parkinson’s disease returns after a hospitalization for pneumonia to start a new Medicare Part A stay.

• Pneumonia is identified as the medical diagnosis on the therapy POT to support skilled therapy services along with therapy treatment diagnosis.

105


Therapy Primary/Medical Diagnosis Example

• However, Parkinson’s disease is the reason for the continued stay and continues to be sequenced first on record and UB-04.

• The reason for the new focus of care and Medicare Part A stay (pneumonia) is sequenced second.

106



Part B Therapy

The UB-04 is also used for Part B billing and the definitions apply in the same manner as for Part A. • FL 67 (Principal Diagnosis) is the reason for continued stay

(Parkinson’s)

• FL 67A (Supporting Diagnosis) is the condition (Difficulty Walking R26.2 )that warrants the need for Part B therapy.

• FL 67B – Q (Additional Diagnoses) conditions which may affect the resident’s progress and help to support therapy services.

• FL 69 (Admitting Diagnosis) is the reason the resident is admitted to receive Part B services (Difficulty Walking R26.2).

107


ICD-10-CM Coding

108

LET’S START SOME SKILL BUILDING



Coding Conventions

in ICD-10-CM

109


Use of the “With” Definition

• The word “with” or “in” means “associated with” or “due to” when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List.

• The classification presumes a causal relationship between the two conditions linked by these terms.

110



“With” Example

Alphabetical Index

• Cough R05– With hemorrhage – See Hemoptysis R04.2

– With Influenza – See Influenza with respiratory manifestations.

Tabular Index• Cough R05 excludes cough with hemorrhage

• Hemoptysis R04.2 includes Blood stained sputum and cough with hemorrhage.

The cough and hemorrhage are related. You would not code both cough and hemoptysis

111


Default Codes

• The default code is listed next to a main term in the ICD-10-CM Alphabetic Index. – Family of codes then listed under main term/default

code

• Represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition.

• If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned. 112



Default Code Example

113

So if you didn’t have any more information than a generic dx of Hypertension, you would use the code next to main term hypertension which is I10


Family of Codes

• “Family of codes” refers to codes that have the same letters/numbers for the first three characters before the decimal.

• We want to use codes from the same “family”– For example, if you are coding E11 for type 2 diabetes,

you pick combination codes from this family of codes.

– You would not want codes from E11 (type 2) on the same diagnosis list/claim with codes from E10 (type 1).

114



Family of Codes Example

• E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified

• E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

• E11.621 Type 2 diabetes mellitus with foot ulcer

**All of these codes could be on same claim since from the same “family” of codes.****

115


Family of Codes Example

• Another example would be choosing same underlying cause of cerebrovascular disease in I69 codes.

– You would want to stay in same number after “.” indicating same underlying cause

I69.021 Dysphasia following nontraumatic subarachnoid hemorrhage

I69.051 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage

NOT:

I69.820 Aphasia following other cerebrovascular disease

116



Placeholder Character

• The ICD-10-CM utilizes a placeholder character “X”.

• The “X” is used as a placeholder for future expansion.

• Where a placeholder exists, the “X” must be used in order for the code to be valid.

• When a 5 character code requires a 7th character, then “X” is used to ensure the 7th character is the 7th character.

117


Placeholder Character – 7th Character

• T81.31 - Disruption of external operation (surgical) wound, not elsewhere classified, - 7th character required to indicate “subsequent encounter”

• The above family of codes requires a 7th character. – Code is only 5 characters

– Add “X” as placeholder to create a valid code

T81.31xD

118



7th Characters

• Certain ICD-10 categories have applicable 7th

characters. The definition varies.

• These 7th characters are required for all codes within the category.

• Seventh characters are provided in the Tabular Index.

• A placeholder must be used to keep the character in the 7th place if the code is not six characters long.

119


7th Characters

The purpose of the 7th character varies

• For injuries: 7th character describes the encounter.

• For glaucoma: 7th character describes the stage

• For diabetes: 7th character denotes laterality

• For external causes of morbidity: 7th character describes the encounter.

• For coding of coma: 7th character describes the location of the assessment.

120



7th Character Example

So S72.001D for example would be Fracture of Unspecified part of neck of right femur, and 7th character D means subsequent encounter for closed fracture with routine healing. The 7th character of “D” indicates this is an aftercare code.

121


Expanded Excludes Notes

• Type 1 and Type 2

• Excludes notes tell you that the code you are looking up excludes a certain diagnosis.

• Each type has different definition for use but similar in that codes excluded from each other are independent of each other.

122



Excludes1 Definition

• A Type 1 Excludes note is a pure excludes note.

• It means “NOT CODED HERE!”

• Exclude note tells you that the excluded diagnosis should never be used with the code you are looking up.

• Means that these codes are mutually exclusive so they are NEVER used together

123


Excludes1 Example

Telling you that aftercare for healing fx is not included in Z47 Orthopedic Aftercare

124



Excludes2 Definition

• An excludes2 note means “NOT INCLUDED HERE!”

• Indicates although the excluded condition is not part of the condition it is excluded from, a patient may have both conditions at the same time.

• May be acceptable to use both the code and the excluded code together if supported by medical record documentation.

125


Excludes2 Example

126

Telling you that fitting and adjustment is excluded but may use both codes



“Code Also” Notes

• A “code also” note instructs that two codes may be required to fully describe a condition. This does not provide sequencing directions.

• The sequencing depends on the circumstances of the encounter.

1 + 1 = 2127


Code Also Example

128



Manifestation / Etiology Codes

• Manifestation Codes represent body system manifestations due to an underlying etiology which are separately classifiable.

• Manifestation Codes cannot be reported as a first-listed or principal diagnosis.

• The underlying disease should be listed first followed by the manifestation code.

129


Manifestation / Etiology Coding

• Code First: Note found at the manifestation code.

• Use Additional Code: Note found at the etiology code.

These instructional notes indicate the proper sequencing of the codes.

130



“Code First”

• When there is a “code first” note and an underlying condition is present, the underlying condition should be sequenced first per “code first” note

131


Code First Example

• Sequence:

– N40.1 BPH

– N13.8 Other obstructive and reflux uropathy

132



“Use Additional Code”

• Found at the etiology (underlying cause) code.

133


“Use Addition Code”Infectious Disease Application

• N30.00 Acute cystitis without hematuria• B96.20 Unspecified Escherichia coli [E. coli]

as the cause of diseases classified elsewhere• The “use additional code” note at category N30

prompts the coder that an additional code is required to identify the infectious agent (organism).

• The instructional note at code sections B95-B97 explain that the codes included in that block are intended to be sequenced as supplementary or additional codes.

134



General Coding Guidelines

in ICD-10-CM

135


DANGER ZONE

The Practitioner MUST look-up code, read coding directions to ensure Accuracy – Use Coding Book or

Coding Website

SHORT CUTS DON’T WORK

Google and your facility software will not provide the detail you need. It is

ONLY found in the Tabular Index!!!! 136



Documentation of Diagnosis

• Assignment of the diagnosis code is based on documentation by the resident’s provider. (physician or other qualified healthcare practitioner legally accountable for establishing the resident’s diagnosis).

137


Code Assignment and Clinical Criteria

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.

• The provider’s statement that the patient has a particular condition is sufficient.

• Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

• Each unique ICD-10-CM diagnosis code may be reported only once for an encounter.

138



Non Physician Documentation

• Documentation by clinicians involved in the resident’s care and who document in the medical record about specific aspects of a resident’s condition. – BMIs

– Pressure Ulcer Staging

– NIH Stroke Scale

– Coma Scale 139


Documentation of Diagnosis

• Keep in Mind: – When Coding from clinician documentation, the

associated diagnosis for the condition (Example: Obesity for BMI) must be documented by the resident’s provider.

– These associated condition codes are never used as a primary diagnosis.

– If conflicting information is documented in the chart, the attending provider should make the final decision. 140



Questionable Principal Diagnosis Codes

141


Z51.89 - Encounter for Other Specified Aftercare

Z51.89 should NEVER be used as a replacement for V57.xx in ICD-10.

– Even though V57.xx crosswalks to Z51.89, this code should not be used for the principal diagnosis for therapy.

– The underlying diagnosis that resulted in the need for therapy would be listed as the principal diagnosisinstead.

– However, Z51.89 could be appropriate in other scenarios if there is not a more specific Aftercare code that applies. 142



Coding Joint Replacements

• Z47: Orthopedic Aftercare should be listed as the principal diagnosis at FL 67 for Elective Joint Replacements.

• The appropriate Z96.xx code, which indicates which joint was replaced, follows at FL 67A.

• When a Joint Replacement follows a fracture, the Fracture Code (with a subsequent encounter such as D as the 7th character) is the Principal Diagnosis NOT the replacement.

143


Antimicrobial Resistance: Z16.xx

• Z16.xx should NEVER be the principal diagnosis.

• Z16.xx indicates that a patient has a condition that is resistant to antimicrobial drug treatment.

• Sequence the infection code first.

144



Therapy Treatment Codes

• Therapy treatment diagnosis codes (such as M62.81 or R26.81, muscle weakness, generalized, unsteadiness on feet, respectively) typically should not be used as the principal diagnosis.

• The condition that is causing these symptoms and the need for therapy should be the principal diagnosis followed by the treatment codes.

145


Common Treatment Codes Used by Physical Therapy

• M62.81 Muscle weakness, generalized

• R26.2 Difficulty walking, not elsewhere classified

• R26.9 Unspecified abnormalities of gait and mobility

• R29.3 Abnormal posture

• R29.6 Repeated falls

146



Common Treatment Codes Used by Occupational Therapy


• R27.8 Other lack of coordination

• R29.3 Abnormal posture

• R53.1 Weakness

• R29.6 Repeated falls

• R41.841 Cognitive Communication deficit

• R63.3 Feeding difficulties

147


Common Treatment Codes Used by Speech Therapy

• R47.9 Unspecified speech disturbances

• R13.10 Dysphagia, unspecified, difficulty swallowing NOS

• R47.01 Aphasia (excludes aphasia following CVA)

• R47.02 Dysphagia, (excludes following a CVA)

• I69.xxx Sequelae of cerebrovascular disease codes

148



COMMON CODING ERRORS IN LTC

149This Photo by Unknown Author is licensed under CC BY


Five Most Common Coding Mistakes

ANAC: Jessie McGill

1. Using unspecified codes

2. Coding resolved diagnoses

3. Incorrect seventh character

4. Coding from the Internet, a cheat sheet, or facility software

5. Coding a diagnosis that was not documented by a physician

150



Using “Unspecified” Codes

• Each healthcare encounter should be coded to the level of certainty known for that encounter.

• In PDPM mapping, most “Unspecified Codes” will not map to a clinical category.

151


Unspecified Laterality Codes

• Unspecified laterality codes should NEVER be utilized in Long Term Care.

• There should never be a code entered that shows we do not know which hip was fractured, where the pressure ulcer was located, or what organism caused the UTI when the culture has been done.

– AND RESULT IN “RETURN TO PROVIDER” FOR PDPM.

• GO LOOK!

152



Coding Resolved Diagnoses

• The resident’s diagnoses should be accurate and current.

• Do not rely on the hospital admission codes as they may no longer be active or relevant.

• Listing infections, such as a UTI or pneumonia, as active diagnoses long after these infections should have resolved is not appropriate.

153


Incorrect Seventh Character

• Seventh Characters are required when indicated.

• Errors occur when the code is copied from the hospital records as they provide the acute care. The SNF is providing subsequent care.

• The need for and correct character to use can ONLY be determined by using the Tabular Index.

154



Coding from the Internet, a Cheat Sheet, or Facility Software

• The ICD-10-CM manual must be used to ensure accurate coding.

• When the correct process is used to locate a code in the ICD-10-CM manual, the coding guidelines can be reviewed and the coding instructions for the item followed.

• Coding from the Internet and software will most typically provide the “unspecified” code.

155


Coding a Diagnosis that was not Documented by a Physician

• Diagnosis cannot be assumed or determined from symptoms documented by licensed nurses or therapists without physician documentation of the diagnosis.

• Review all available documentation and make a list of physician/physician extender documented diagnoses.

• Review for the current status of the diagnosis.

• Query the physician if questions. 156



Coding Issues Identified

• Using unspecified codes – for example, using code for Chronic CHF when medical record specified Acute on Chronic Diastolic or Systolic CHF.

OR

• Using greater specificity than was supported by EHR.

157



• Failure to code the primary diagnosis as the first-listed diagnosis – placing it somewhere down the line.

• Failure to include therapy treatment codes in the first eight codes in the sequence in order for them to be included on electronic claim.

Remember: CMS only sees the first 8 diagnoses on an electronic claim.

158




• Incorrect laterality as compared to EHR.

• Improper sequence according to priority of codes.

• Incorrect codes used.

• Failure to list diagnoses that support the plan of treatment. • Not including the organism when there is an infection

OR

• Coding the organism but not the infection.– Remember, the infection should be listed first, followed by the

organism (when known).

159


Communication is Key

160



ICD-10-CM

Case Studies with PDPM Impact

161


Coding Example#1

Resident is admitted to Shiny Skies Nursing and Rehabilitation Center following a CVAresulting in Left-Sided Hemiparesis and Dysphagia that required placement of a G-tube and G-tube feedings will be 50% of calories. Resident is left handed. Resident also has Type II Diabetes. Resident will be receiving PT for gait training, OT for muscle weakness, and SLP for dysphagia.

162



ICD-10-CM Answers for Coding Example #1:

– I69.991 Dysphagia following unspecified cerebrovascular disease OR

−I69.952 Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side

– Z43.1 Attention to gastrostomy – E11.59 Type II Diabetes with other circulatory

complications– R26.9 Unspecified abnormalities of gait/mobility– M62.81 Muscle weakness, generalized– R13.10 Dysphagia, unspecified

163


PDPM Impact for Coding Example #1:ICD-10 Code I0020B/First listed I8000

PT, OT CMG/SLP CMG

Surgical Procedure

NTA Comorbidity Qualifier

SLP ComorbidityQualifier

I69.952 Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (Either I69 code qualifies for Acute Neuro for SLP but I69.991 can be second-listed since SLP comorbidity)

Non-Ortho SurgeryAcute Neuro/

Acute Neuro

N/A Feeding tube = 1 point (K0510B2)

Diabetes = 2 points

Yes, hemiplegia/Hemiparesis

Swallowing disorder

Dysphagia

(Be sure to list all I69 codes in I8000 for SLP comorbidities –I69.991) 164



Coding Example#2

Resident is admitted to your facility status post traumatic fracture of the right greater trochanter (displaced). Resident presented with a Stage II pressure ulcer on both heels and coccyx. Resident will be receiving both PT and OT services. Resident also has a diagnosis of Essential Hypertension. PT will be treating resident for Difficulty Walking and OT for muscle weakness.

165



− S72.111D Displaced fracture of greater trochanter of right femur subsequent encounter for closed fracture with routine healing (7th character “D”)

− R26.2 Difficulty in walking, not elsewhere classified

− M62.81 Muscle weakness, generalized

− L89.612 Pressure ulcer of right heel, stage 2

− L89.622 Pressure ulcer of left heel, stage 2

− L89.152 Pressure ulcer of sacral region, stage 2

− I10 Essential (primary) Hypertension

166



PDPM Impact for Coding Example #2:

ICD-10 Code I0020B/First listed I8000

PT, OT CMG/SLP CMG

Surgical Procedure



S72.111D Displaced fracture of greater trochanter of right femur, subsequent encounter for closed fracture with routine healing

Ortho Surgery (Except Major Joint Replace or Spinal Surgery)/

Non Neuro

N/A None None

167


Coding Example #3

Resident is admitted to Home Sweet Home following abdominal surgery for bowel obstruction. Resident has post operative superficial wound that requires BID dressing changes due to abdominal dehiscence. Resident also has newly diagnosed UTI with E. Coli isolated in the culture. Resident is symptomatic with frequency, urgency and burning upon urination. Resident will be receiving IV antibiotics x3 days. Resident will not receive therapy upon admission.

168




− T81.31xD Disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter

− Z48.815 Encounter for surgical aftercare following surgery on the digestive system

− Z48.01 Encounter for change or removal of surgical wound dressing

− N39.0 Urinary tract infection, site not specified

− B96.20 Unspecified E. coli, as the cause of diseases classified elsewhere

169




PT, OT CMG/SLP CMG

Surgical Procedure



T81.31xD Disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter

Medical Mgmt/

Non-Neuro

N/A IV medications = 5 points

None

170



Coding Example#4

Resident is admitted to Shady Grove after repair of a Fractured Left Hip sustained due to a fall. Resident has Left Hip Osteoarthritis from dysplasia with chronic NSAID use. Additional diagnoses include Essential Hypertension, Sinus Bradycardia and Hyperlipidemia. Admission orders include lab work to monitor effect of Simvastatin and Omacor. Resident will be receiving PT for treatment of difficulty walking and OT therapy services for muscle weakness.

171



− S72.002D Fx of unspecified part of neck of left femur

−M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip

− Z79.1 Long-term (current) use of NSAIDS

− Z79.899 Other long term (current) drug therapy

− Z51.81 Therapeutic drug level monitoring

172




Continued

−R26.2 Difficulty in walking, not elsewhere classified

−M62.81 Muscle weakness, generalized

−R00.1 Bradycardia, unspecified

− I10 Hypertension (essential)

−E78.5 Hyperlipidemia (unspecified)

173




PT, OT CMG/SLP CMG

Surgical Procedure



S72.002D Fx of unspecified part of neck of left femur, subsequent encounter closed fx with routine healing

Ortho Surgery (Except Major Joint Replace or Spinal Surgery)/

Non-Neuro

N/A None None

174



Coding Example#5

Resident was admitted to Daisy May SNF following a right total hip replacement at the hospital due to primary unilateral Osteoarthritis of right hip. Resident will be receiving PT for gait training due to difficulty walking. Resident will be receiving OT for muscle weakness.

175



− Z47.1 Aftercare following joint replacement surgery (Note to use additional code to identify the joint (Z96.6-)

− Z96.641 Presence of right artificial hip joint

− M16.11 Unilateral primary osteoarthritis, right hip

− R26.2 Difficulty in walking, not elsewhere classified

− M62.81 Muscle weakness, generalized

176





PT, OT CMG/SLP CMG

Surgical Procedure



Z47.1 Aftercare following joint replacement surgery (Note to use additional code to identify the joint (Z96.6-)

Major Joint Replace or Spinal Surgery/

Non-Neuro

N/A None None

177


Case Studies

Review the Case Study to Identify:

Principal/I0020B/First-listed I8000 Diagnosis

Admitting/I0020B/First-listed I8000 Diagnosis

Additional Diagnoses

Determine proper sequencing

178



Hip Fracture/Hip Replacement Case Study

89 Y/O female admitted to Daisy May Hospital for a greater trochanter fracture of left hip following a fall. It was determined that she needed a left hip replacement. Patient is receiving prophylactic anticoagulant Lovenox and also has a diagnosis of Diabetes Type II and Senile Dementia with moderate cognitive impairment.

179


Hip Fracture Case Study

Hospital Discharge Diagnoses:

• Fracture of Left Greater Trochanter

• Left Hip Replacement

• Osteoporosis

• Type II Diabetes

• Senile Dementia

180




SNF Orders:

• PT and OT to eval and treat as indicated

• PT will be providing gait training for Difficulty Walking

• OT will be providing therapeutic activities and ADL retraining for muscle weakness

• Continue Lovenox therapy

181



• I0020B/First-listed diagnosis on MDS I8000/What is the admitting diagnosis (FL 69) for the claim?

• I0020B/First-listed diagnosis on MDS I8000/What is the principal diagnosis (FL 67) for the claim?

• Additional MDS I8000 diagnoses/List in order the other diagnoses (FL 67a-q) for the claim.

182



Hip Fracture Case Study Answers

I0020B/First Listed I8000/Admitting diagnosis for claim (FL 69):

• S72.112D, Displaced fracture of greater trochanter of left femur, 7th character D for subsequent encounter for closed fracture with routine healing.

I0020B/First-listed I8000/Principal diagnosis for claim (FL 67):

• S72.112D, Displaced fracture of greater trochanter of left femur, 7th character D for subsequent encounter for closed fracture with routine healing.

183


Hip Fracture Case Study Answers

Additional I8000 Diagnoses/Subsequent Diagnoses in order of priority: (FL 67A-Q):

• Z96.642 Presence of left artificial hip joint

• E11.9 Type II Diabetes

• R26.2 Difficulty in walking, not elsewhere classified


• Z79.01 Long-term (current use) of anticoagulants

• F03.90 Unspecified Dementia, Senile Dementia NOS

**Remember to use injury code as primary for joint replacements resulting from injury** 184



PDPM Impact for Hip Fracture Case Study:


PT, OT CMG/SLP CMG

Surgical Procedure



S72.112D, Displaced fracture of greater trochanter of left femur, 7th character D for subsequent encounter for closed fracture with routine healing

Ortho Surgery (Except Major Joint Replace or Spinal Surgery/

Non-Neuro

N/A Diabetes = 2 points

No

But does qualify for cognitive impairment (moderate cognitive impairment)

185


CVA Case Study

79 y/o male admitted to Memorial Hospital after daughter found him slurring his words and unable to move left arm. Gentleman is Left Handed. Hospital determined that patient had suffered a Cerebrovascular Accident (CVA) from a blood clot. Patient will be on long-term Lovenox therapy and is receiving PT, OT, and SLP therapies for gait training, muscle weakness, and aphasia.Patient also developed a Stage 2 pressure ulcer on right buttocks during hospital stay.

186



CVA Case Study

Discharge Diagnoses from hospital:

Acute CVA (I63.9)

Aphasia

Left Hemiparesis

Stage 2 pressure ulcer to right buttocks

187


CVA Case Study

• I0020B/First-listed diagnosis on MDS I8000/What is the admitting diagnosis (FL 69) for the claim?

• I0020B/First-listed diagnosis on MDS I8000/What is the principal diagnosis (FL 67) for the claim?

• Additional MDS I8000 diagnoses/List in order the other diagnoses (FL 67a-q) for the claim.

188



CVA Case Study Answers

I0020B/First Listed I8000/Admitting diagnosis for claim (FL 69):

• I69.920 Aphasia following unspecified cerebrovascular disease or • I69.952 Hemiplegia and hemiparesis following unspecified

cerebrovascular disease affecting left dominant side

I0020B/First Listed I8000/Principal diagnosis for claim (FL 67):

• I69.920 Aphasia following unspecified cerebrovascular disease or• I69.952 Hemiplegia and hemiparesis following unspecified

cerebrovascular disease affecting left dominant side189


CVA Case Study Answers

Additional I8000 Diagnoses/Subsequent Diagnoses in order of priority (FL 67A-Q):

• I69.920 Aphasia following unspecified cerebrovascular disease or

• I69.952 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side (which ever wasn’t used as primary)

• M62.81 Muscle weakness, generalized• R26.9 Unspecified abnormalities of gait and mobility• Z79.01 Long-term (current use) of anticoagulants• L89.312 Pressure Ulcer of Right Buttocks, Stage 2

190



PDPM Impact for CVA Case Study:ICD-10 Code I0020B/First listed I8000

PT, OT CMG/SLP CMG

Surgical Procedure



I69.920 Aphasia following unspecified cerebrovascular disease or I69.952 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side (Either code qualifies for Acute Neuro for PT, OT, and SLP)

Acute Neuro/

Acute Neuro

N/A None Yes, AphasiaHemiplegiaCVA(Be sure to

code all of these in I4300, I4900, I4500 and in I8000 to qualify for comorbidities)

191


ICD-10-CM Websites

192



ICD-10-CM Websites

• CDChttp://www.cdc.gov/nchs/icd/icd10cm.htm

• CMShttps://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-CM.html

• ICD-10-CM Codeshttp://www.icd10data.com

193


ICD-10-CM Websites

AHIMA

• ICD-10 General Information

http://www.ahima.org/icd10

• CMS Look-Up Tool that allows users to search for codes by ICD-10 description keywords:

https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx

194



Final Words

• Selecting an accurate ICD-10-CM code for I0020B/I8000 that supports primary reason for admission will then lead to an accurate Admission/Principal diagnosis on claim

• MDS list in I8000 should drive the order of diagnoses on the Diagnosis List especially if used to populate claim

• To a certain degree the ICD-10 Code “Is what it is” as long as you are properly looking up codes

195


Final Words

• For Accuracy now, and to prepare for PDPM, consider practicing:

– Learn to correctly look up codes to ensure specificity and to follow coding conventions such as: “with” or “code also” or “code first” notes for that code

– Ensure current coding book and access to websites

– Begin putting Admitting/Principal diagnosis in I8000 first listed

• Practice looking up that code in Clinical Mapping spreadsheet to learn what Clinical Category is achieved and/or would a Hospital Surgical Procedure change the default clinical category. 196



Final Words

– As other diagnoses are identified, search NTA Mapping spreadsheet to determine if they qualify for a comorbidities and if so how many points

– Check if any codes impact SLP comorbidities

• Include all these codes in I8000

• The above process will help “learn” the mapping of ICD-10 codes and ultimately what Clinical Category you achieve and what NTA/SLP comorbidities you would capture

197


Post Test

198


Patient-Driven Payment Model (PDPM): Quick Reference

The PDPM establishes a rate on the 5-day MDS for the entire stay by combining five different case-mix components (PT, OT, SLP, Nursing, and Non-Therapy Ancillary) with the non-case mix component (a total of 6 components). A variable rate applies for three components based on length of stay). The rate may be changed during the Medicare Part A stay by completing the voluntary Interim Payment Assessment (IPA) for substantial changes.

Use the following tools to identify the case-mix group for each component and improve your understanding of the Patient-Driven Payment Model.

– https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

Final Rule http://s3.amazonaws.com/public‐inspection.federalregister.gov/2018‐16570.pdf

Non‐Case‐Mix Group

PT

Case‐Mix

Group OT

PT

Case-Mix

GroupOT

Case-Mix

Group

SLP

Case-Mix

GroupNursing Case-Mix

Group

Non-Therapy Ancillary Case-Mix

Group

Non-Case-Mix

Group=

Resident’s Total Rate


Steps for ICD-10 to PDPM Clinical Mapping

To determine a resident’s clinical category, complete the following steps:

1. Locate the ICD-10 code for the primary reason for SNF care in the tab “SNF_clinical_categories_by_dx”

2. Use the mapping in this tab to determine the default category, in column C

3. Did the resident receive a surgical procedure during the prior inpatient stay that relates to the SNF care plan?

“N/A” – Clinical Category is the default clinical category - STOP

NO

YES

4. Use column D to determine if the resident is eligible for a different clinical category from the default.

5. Is the resident eligible for a different clinical category?

NO

Clinical Category is the default clinical category - STOP

YES, NON-ORTHO

SURGERY

6. Use the tab “Non_Ortho_Surgery” to see if the resident had a qualifying inpatient procedure.

7. Did the resident have a qualifying non-orthopedic procedure?

NO


YES

Clinical category is Non-Orthopedic Surgery - STOP

YES, ORTHO

SURGERY

8. If the resident is eligible for one of the two orthopedic surgery categories, then use the “Orthopedic_Surgery” tab to determine if the resident had a qualifying inpatient procedure.

9. Did the resident have a qualifying orthopedic procedure?

NO


YES

Use column C to determine the clinical category based on the ICD-10-PCS code corresponding to the inpatient procedure – STOP

You can search by ICD-10 code, code description, A to Z, or Z to A. Not all codes are listed, so if actual code doesn’t come up, search by another method. May be necessary to scroll down to locate code manually.

Do not use decimal when searching by ICD-10 code.


Physical Therapy & Occupational Therapy Component Patient-Driven Payment Model (PDPM)

Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs.

PT & OT Clinical Category

(Collapsed)

GG Function

Score

PT & OT Case Mix

Group

PT CMI

OT CMI

Primary Diagnosis (PDPM Clinical Category)


0-5 6-9

10-23 24

TA TB TC TD

1.53 1.69 1.88 1.92

1.49 1.63 1.68 1.53

Major Joint Replacement or Spinal Injury

Other Orthopedic 0-5 6-9

10-23 24

TE TF TG TH

1.42 1.61 1.67 1.16

1.41 1.59 1.64 1.15

Orthopedic Surgery (except major joint replacement or spinal surgery) Non-surgical orthopedic/ musculoskeletal

Medical Management

0-5 6-9

10-23 24

TI TJ TK TL

1.13 1.42 1.52 1.09

1.17 1.44 1.54 1.11

Acute infections Cardiovascular and Coagulations Pulmonary Cancer Medical Management

Non-Orthopedic Surgery & Acute Neurologic

0-5 6-9

10-23 24

TM TN TO TP

1.27 1.48 1.55 1.08

1.30 1.49 1.55 1.09

Non-orthopedic surgery Acute Neurologic

*PT Component and OT Component: PT and OT components will always result in the same case-mix group; however, the PT and OT case-mix indices/payment levels differ.

Scoring Response for Section GG Items Score Section GG Items Score

05, 06 Set-up assistance, independent 4 GG0130A1 Self-care: Eating 0-4 04 Supervision or touching assistance 3 GG0130B1 Self-care: Oral hygiene 0-4 03 Partial/moderate assistance 2 GG0130C1 Self-care: Toileting

hygiene 0-4

02 Substantial/maximal assistance 1 GG0170B1 Mobility: Sit to lying 0-4 (avg. of 2 bed

mobility items) GG0170C1 Mobility: Lying to sitting on side of bed

01, 07, 09, 10, 88, [-]

Dependent, refused, not attempted, resident does not walk**

0 GG0170D1 Mobility: Sit to stand 0-4 (avg. of 3

transfer items) GG0170E1 Mobility: Chair/bed-to-

chair transfer GG0170F1 Mobility: Toilet transfer

GG0170J1 Mobility: Walk 50 feet with 2 turns

0-4 (avg. of 2

walking items) GG0170K1 Mobility: Walk 150 feet

** If a resident is coded as not attempted (07, 09, 10, or 88) for GG0170l1 (Walk 10 feet), then walking items for

GG0170J1 (Walk 50 feet with 2 turns) and GG0170K1 (Walk 150 feet) will be scored as zero points.


Physical Therapy & Occupational Therapy Component Patient-Driven Payment Model (PDPM)


Medicare Payment Days Adjustment Factor 1-20 1.00 21-27 0.98 28-34 0.96 35-41 0.94 42-48 0.92 49-55 0.90 56-62 0.88 63-69 0.86 70-76 0.84 77-83 0.82 84-90 0.80 91-97 0.78 98-100 0.76


Speech-Language Pathology Component Patient-Driven Payment Model (PDPM)


Presence of Acute Neurologic Condition/ SLP-Related Comorbidity/

OR Cognitive Impairment (Mild, Moderate, Severe)

Mechanically Altered Diet OR Swallowing Disorder

SLP Case-Mix

Group

SLP Case-Mix

Index

None Neither SA 0.68

None Either SB 1.82

None Both SC 2.66

Any One Neither SD 1.46

Any One Either SE 2.33

Any One Both SF 2.97

Any Two Neither SG 2.04

Any Two Either SH 2.85

Any Two Both SI 3.51

All Three Neither SJ 2.98

All Three Either SK 3.69

All Three Both SL 4.19

Primary Diagnosis Clinical Category SLP Clinical Category Major Joint Replacement or Spinal Surgery Non-Neurologic

Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Non-Neurologic

Non-Orthopedic Surgery Non-Neurologic

Acute Infections Non-Neurologic

Cardiovascular and Coagulations Non-Neurologic

Pulmonary Non-Neurologic

Non-Surgical Orthopedic/Musculoskeletal Non-Neurologic

Acute Neurologic Acute Neurologic

Cancer Non-Neurologic

Medical Management Non-Neurologic




Co-morbidity Special Treatments, Procedures and Programs

O0100 O0100E2 Tracheostomy Care I0100F2 Ventilator or Respirator

Section I: Active Diagnoses I4300 Aphasia (R47.01, F80.2, F80.‐, I69.‐, G31.01) I4900 Hemiplegia or Hemiparesis (G81.‐, G83.‐, I69.‐) I4500 CVA, TIA, or Stroke (I69.‐) I5500 TBI (S06.‐)

Other: I8000 Additional Active Diagnoses

See ICD-10 Codes below

Laryngeal Cancer Apraxia Dysphagia ALS Oral Cancers Speech and Language Deficits

SLP-Related Co-morbidity ICD-10-

CM Code Description

ALS G12.21 Amyotrophic lateral sclerosis Apraxia I69.990 Apraxia following unspecified cerebrovascular disease Dysphagia I69.991 Dysphagia following unspecified cerebrovascular disease Laryngeal Cancer C32.0 Malignant neoplasm of glottis Laryngeal Cancer C32.1 Malignant neoplasm of supraglottis Laryngeal Cancer C32.2 Malignant neoplasm of subglottis Laryngeal Cancer C32.3 Malignant neoplasm of laryngeal cartilage Laryngeal Cancer C32.8 Malignant neoplasm of other specified sites of larynx Laryngeal Cancer C32.9 Malignant neoplasm of larynx, unspecified Oral Cancer C00.0 Malignant neoplasm of external upper lip Oral Cancer C00.1 Malignant neoplasm of external lower lip Oral Cancer C00.3 Malignant neoplasm of upper lip, inner aspect Oral Cancer C00.4 Malignant neoplasm of lower lip, inner aspect Oral Cancer C00.5 Malignant neoplasm of lip, unspecified, inner aspect Oral Cancer C00.6 Malignant neoplasm of commissure of lip, unspecified Oral Cancer C00.8 Malignant neoplasm of overlapping sites of lip Oral Cancer C00.2 Malignant neoplasm of external lip, unspecified Oral Cancer C00.9 Malignant neoplasm of lip, unspecified Oral Cancer C01 Malignant neoplasm of base of tongue Oral Cancer C02.0 Malignant neoplasm of dorsal surface of tongue Oral Cancer C02.1 Malignant neoplasm of border of tongue Oral Cancer C02.2 Malignant neoplasm of ventral surface of tongue Oral Cancer C02.3 Malignant neoplasm of anterior two-thirds of tongue, part

unspecified Oral Cancer C02.8 Malignant neoplasm of overlapping sites of tongue Oral Cancer C02.4 Malignant neoplasm of lingual tonsil





CM Code Description

Oral Cancer C02.9 Malignant neoplasm of tongue, unspecified Oral Cancer C03.0 Malignant neoplasm of upper gum Oral Cancer C03.1 Malignant neoplasm of lower gum Oral Cancer C03.9 Malignant neoplasm of gum, unspecified Oral Cancer C04.0 Malignant neoplasm of anterior floor of mouth Oral Cancer C04.1 Malignant neoplasm of lateral floor of mouth Oral Cancer C04.8 Malignant neoplasm of overlapping sites of floor of mouth Oral Cancer C04.9 Malignant neoplasm of floor of mouth, unspecified Oral Cancer C09.9 Malignant neoplasm of tonsil, unspecified Oral Cancer C09.8 Malignant neoplasm of overlapping sites of tonsil Oral Cancer C09.0 Malignant neoplasm of tonsillar fossa Oral Cancer C09.1 Malignant neoplasm of tonsillar pillar (anterior)(posterior) Oral Cancer C10.0 Malignant neoplasm of vallecular Oral Cancer C10.1 Malignant neoplasm of anterior surface of epiglottis Oral Cancer C10.8 Malignant neoplasm of overlapping sites oropharynx Oral Cancer C10.2 Malignant neoplasm of lateral wall of oropharynx Oral Cancer C10.3 Malignant neoplasm of posterior wall of oropharynx Oral Cancer C10.4 Malignant neoplasm of branchial cleft Oral Cancer C10.8 Malignant neoplasm of overlapping sites of oropharynx Oral Cancer C10.9 Malignant neoplasm of oropharynx, unspecified Oral Cancer C14.0 Malignant neoplasm of pharynx, unspecified Oral Cancer C14.2 Malignant neoplasm of waldeyer’s ring Oral Cancer C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and

pharynx Oral Cancer C06.0 Malignant neoplasm of cheek mucosa Oral Cancer C06.1 Malignant neoplasm of vestibule of mouth Oral Cancer C05.0 Malignant neoplasm of hard palate Oral Cancer C05.1 Malignant neoplasm of soft palate Oral Cancer C05.2 Malignant neoplasm of uvula Oral Cancer C05.9 Malignant neoplasm of palate, unspecified Oral Cancer C05.8 Malignant neoplasm of overlapping sites of palate Oral Cancer C06.2 Malignant neoplasm of retromolar area Oral Cancer C06.89 Malignant neoplasm of overlapping sites of other parts of mouth Oral Cancer C06.80 Malignant neoplasm of overlapping sites of unspecified parts of

mouth Oral Cancer C06.9 Malignant neoplasm of mouth, unspecified Speech and Language Deficits

I69.928 Other speech and language deficits following unspecified cerebrovascular disease

Speech and Language Deficits

I69.920 Aphasia following unspecified cerebrovascular disease


I69.921 Dysphasia following unspecified cerebrovascular disease





CM Code Description


I69.922 Dysarthria following unspecified cerebrovascular disease


I69.923 Fluency disorder following unspecified cerebrovascular disease


I69.928 Other speech and language deficits following unspecified cerebrovascular disease

Cognitive Impairment

PDPM Cognitive Level BIMS Score Staff Assessment Score

1-Cognitively Intact 13-17 0

2-Mildly Impaired 8-12 1-2

3-Moderately Impaired 0-7 3-4

4-Severely Impaired - 5-6

Mild to Severe Cognitive Impairment BIMS Interview Summary Score 0-15

To qualify as Cognitively Impaired – must be

Mild, Moderate or Severely Impaired

PDPM Cognitive Level BIMS Score Cognitively Intact Mildly Impaired

Moderately Impaired Severely Impaired

13-15 8-12 0-7 -

If BIMS Interview Summary Score is 99 or “-“ Use Staff Assessment for PDPM Cognitive Level per Calculation Worksheet


Steps for ICD-10 to PDPM NTA Comorbidity Mapping

1. Determine if the ICD-10 code is listed in the NTA Comorbidity Mappings.

2. Is the ICD-10 code listed as an NTA Comorbidity Qualifier?

Then the ICD-10 code is not an NTA I8000 Comorbidity Qualifier – STOP

(Keep in mind resident may still qualify for other MDS item NTA Comorbidity Qualifiers unrelated to ICD-10 I8000.)

NO

YES

4. Use column B to determine the NTA Comorbidity Qualifying Category.

You can search by ICD-10 code, ICD-10 code description, or Comorbidity description. Use drop down boxes to enter information or you can sort A to Z, or Z to A.

Do not use decimal when searching by ICD-10 code.

Make sure you are using the most up-to-date version of the NTA Comorbidity Mappings.


Non-Therapy Ancillary (NTA) Component Patient-Driven Payment Model (PDPM)


Condition/Extensive Service Source Points

HIV/AIDS SNF Claim 8 Parenteral IV Feeding: Level High MDS Items K0510A2 &

K0710A2=3 7

Special Treatments/Programs: Intravenous Medication Post-admit Code MDS Item O0100H2 5 Special Treatments/Programs: Ventilator or Respirator Post-admit Code MDS Item O0100F2 4 Parenteral IV Feeding: Level Low MDS Items K0510A2 &

K0710A2=2 & K0710B2=2 3

Lung Transplant Status MDS Item I8000 3 Special Treatments/Programs: Transfusion Post-admit Code MDS Item O0100I2 2 Major Organ Transplant Status, Except Lung MDS Item I8000 2 Active Diagnoses: Multiple Sclerosis Code MDS Item I5200 2 Opportunistic Infections MDS Item I8000 2 Active Diagnoses: Asthma COPD Chronic Lung Disease Code MDS Item I6200 2 Bone/Joint/Muscle Infections/Necrosis – Except Aseptic Necrosis of Bone MDS Item I8000 2 Chronic Myeloid Leukemia MDS Item I8000 2 Wound Infection Code MDS Item I2500 2 Active Diagnoses: Diabetes Mellitus (DM) Code MDS Item I2900 2 Endocarditis MDS Item I8000 1 Immune Disorders MDS Item I8000 1 End-Stage Liver Disease MDS Item I8000 1 Other Foot Skin Problems: Diabetic Foot Ulcer Code MDS Item M1040B 1 Narcolepsy and Cataplexy MDS Item I8000 1 Cystic Fibrosis MDS Item I8000 1 Special Treatments/Programs: Tracheostomy Care Post-admit Code MDS Item O0100E2 1 Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1 Special Treatments/Programs: Isolation Post-admit Code MDS Item O0100M2 1 Specified Hereditary Metabolic/Immune Disorders MDS Item I8000 1 Morbid Obesity MDS Item I8000 1 Special Treatments/Programs: Radiation Post-admit Code MDS Item O0100B2 1 Highest Stage of Unhealed Pressure Ulcer – Stage 4 MDS Item M0300D1 1 Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1 Chronic Pancreatitis MDS Item I8000 1 Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1 Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code (M1040B)

MDS Item M1040A& M1040C 1

Complications of Specified Implanted Device or Graft MDS Item I8000 1 Bladder and Bowel Appliances: Intermittent Catheterization MDS Item H0100D 1 Inflammatory Bowel Disease MDS Item I8000 1 Aseptic Necrosis Bone MDS Item I8000 1 Special Treatments/Programs: Suctioning Post-admit Code MDS Item O0100D2 1 Cardio-Respiratory Failure and Shock MDS Item I8000 1 Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1 Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies

MDS Item I8000 1


Non-Therapy Ancillary (NTA) Component Patient-Driven Payment Model (PDPM)


Condition/Extensive Service Source Points

Diabetic Retinopathy – Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

MDS Item I8000 1

Nutritional Approaches While a Resident: Feeding Tube MDS Item K0510B2 1 Severe Skin Burn or Condition MDS Item I8000 1 Intractable Epilepsy MDS Item I8000 1 Active Diagnoses: Malnutrition Code MDS Item I5600 1 Disorders of Immunity – Except: RxCC97: Immune Disorders MDS Item I8000 1 Cirrhosis of Liver MDS Item I8000 1 Bladder and Bowel Appliances: Ostomy MDS Item H0100C 1 Respiratory Arrest MDS Item I8000 1 Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Items I8000 1

NTA Score Range NTA Case-Mix Group CMI

12+ NA 3.25 9-11 NB 2.53 6-8 NC 1.85 3-5 ND 1.34 1-2 NE 0.96 0 NF 0.72

Medicare Payment Days Adjustment Factor

1-3 3.0 4-100 1.0


Nursing Component Patient-Driven Payment Model (PDPM)


Clinical Category

PDPM Nursing

Case-Mix Group

Clinical Conditions

Depression

# of Restorative

Nursing Services

GG-based

Function Score

Nursing Case-Mix

Index

Extensive Services

ES3 Tracheostomy &

Ventilator - - 0-14 4.04

ES2 Tracheostomy or

Ventilator - - 0-14 3.06

ES1 Infection - - 0-14 2.91

Special Care High

HDE2

Serious medical conditions e.g.

comatose, septicemia,

respiratory therapy

Yes - 0-5 2.39

HDE1



respiratory therapy

No - 0-5 1.99

HBC2



respiratory therapy

Yes - 6-14 2.23

HBC1



respiratory therapy

No - 6-14 1.85

Special Care Low

LDE2


radiation therapy or dialysis

Yes - 0-5 2.07

LDE1



No - 0-5 1.72

LBC2



Yes - 6-14 1.71




Clinical Category

PDPM Nursing

Case-Mix Group

Clinical Conditions

Depression

# of Restorative

Nursing Services

GG-based

Function Score

Nursing Case-Mix

Index

Special Care Low LBC1



No - 6-14 1.43

Clinically Complex

CDE2

Conditions requiring complex medical

care e.g. pneumonia, surgical wounds,

burns

Yes - 0-5 1.86

CDE1



burns

No - 0-5 1.62

CBC2



burns

Yes - 6-14 1.54

CA2



burns

Yes - 15-16 1.08

CBC1



burns

No - 6-14 1.34

CA1



burns

No - 15-16 0.94

Behavior SX Cognition

BAB2 Behavioral or

cognitive symptoms - 2 or more 11-16 1.04

BAB1 Behavioral or

cognitive symptoms - 0-1 11-16 0.99




Clinical Category

PDPM Nursing

Case-Mix Group

Clinical Conditions

Depression

# of Restorative

Nursing Services

GG-based

Function Score

Nursing Case-Mix

Index

Reduced Physical Function

PDE2 Assistance with daily living and

general supervision - 2 or more 0-5 1.57

PDE1 Assistance with daily living and

general supervision - 0-1 0-5 1.47

PBC2 Assistance with daily living and


PA2 Assistance with daily living and


PBC1 Assistance with daily living and


PA1 Assistance with daily living and


Scoring Response for Section GG Items Score Section GG items Score

05, 06 Set-up assistance, independent 4 GG0130A1 Self-care: Eating 0-4

04 Supervision or touching assistance

3 GG0130C1 Self-care: Toileting hygiene

0-4

03 Partial/moderate assistance 2 GG0170B1 Mobility: Sit to lying 0-4 (avg. of 2 bed

mobility items)

02 Substantial/maximal assistance 1 GG0170C1 Mobility: Lying to sitting on side of bed

01, 07, 09, 10, 88, [-]

Dependent, refused, not attempted

0 GG0170D Mobility: Sit to stand 0-4

(avg. of 3 transfer items)

GG0170E1 Mobility: Chair/bed-to-chair transfer

GG0170F1 Mobility: Toilet transfer

*Nursing Component: See the CMS PDPM calculation worksheet for inclusion criteria for each nursing classification.


PDPM Payments Slope and Create Incentives for Shorter LOS

Costs

Payments

Total Per Diem Payment is the Sum of Payments for Each Component

NTA, OT, and PT taper or decrease over stay. Nursing, SLP, and Non-Case Mix Group remain constant.

NTA – Triple rate first 3 days; normal rate for rest of stay unless complete an Interim Payment Assessment which may change the rate for this component but does not reset to Day One of stay.

OT and PT rates taper 2% every 7 days starting on day 21. Payments Can be Adjusted Using the Interim Payment Assessment (IPA) but

the IPA does not reset to Day One for tapering Components

FY 2019 PDPM Unadjusted Federal Rate Per Diem - Urban

Rate Component

Nursing NTA PT OT SLP Non-Case-

Mix

Per Diem Amount

$103.46 $78.05 $59.33 $55.23 $22.15 $92.63

FY 2019 PDPM Unadjusted Federal Rate Per Diem - Rural

Rate Component

Nursing NTA PT OT SLP Non-Case-

Mix

Per Diem Amount

$98.83 $74.56 $67.63 $62.11 $27.90 $94.34


PROCEDURE FOR SELECTING PRIMARY REASON FOR ADMISSION

Steps for Selection of Primary Reason for Admission (I0200B/I8000) and Identifying all Comorbidities

PURPOSE: Ensure correct diagnoses are included in the medical record, on MDS Section I including I8000, on the therapy plan of treatments, and communicated to the billing office to follow through to the eventual UB-04 claim. Using proper diagnosis codes will reduce risk of ADRs and denials and ensure proper payment under PDPM.

STEP ONE:

a) Within 24 to 48 hours identify ALL CURRENT diagnoses. b) Ensure you are identifying accurate, specific codes within 48 hours. c) Seek additional information when needed for coding all comorbidities.

STEP TWO: IDT to review all pertinent diagnoses. Many diagnoses will be obvious for Primary Reason for Admission:

Stroke

Hip Fracture

Hip/Knee Replacement (Remember to use fracture if replacement is due to fracture) Also pursue any additional diagnoses with a serious look at history which could impact comorbidity coding. STEP THREE:

a) By day 7, IDT to determine, finalize selection of Primary Diagnosis for coding I0020B & I8000 • If not sure which of the identified ICD-10 codes achieves the highest CMG, then run diagnosis through the

Clinical Mapping. • Choose ICD-10 codes with highest impact on CMG from Clinical Mapping.

STEP FOUR:

a) List all other pertinent Diagnoses in I8000 to support NTA and/or SLP comorbidities.

STEP FIVE: a) Medical Diagnosis List created by day 7 in priority order for claim

• Suggest I0020B & I8000 be listed first • List codes that support:

Skilled Services NTA comorbidity points SLP comorbidities

• Include therapy treatment diagnoses

Developed by Polaris Group (12.18) www.polaris-group.com


PROCEDURE FOR SELECTING PRIMARY REASON FOR ADMISSION, continued

Diagnosis List

1. Complete the diagnosis list within seven days of admission/readmission, when a new diagnosis arises, quarterly with MDS schedule, and monthly prior to Medicare A billing. If an MDS has to be completed for HMO or private insurance purposes, then the diagnosis list will need to be completed as well.

2. Diagnoses should be obtained from the following sources: hospital progress notes, transfer documentation, discharge summary, physician orders, etc.

3. There are three categories of diagnoses which should be placed on the diagnosis list: a. All diagnoses checked on Section I (I0100 – I7900) of the corresponding MDS b. All I8000 diagnoses including First-listed & I0020B which is the primary reason for admission c. All diagnoses listed on therapy plan of treatments (POTs) if applicable for that stay Please note the following: *Each diagnosis must have a corresponding ICD-10-CM code listed *The “Principal Dx” (primary reason for admission) is the diagnosis chiefly responsible for the admission to the SNF or the reason for the continued stay. Remember, that it may be a Z code. *Remember to take each diagnosis to the furthest number of characters (3-7). A diagnosis code is not

valid if it is not taken to the furthest number of characters which allows for greater specificity. 1st

character will be alpha and then characters 2-7 can be alpha or numeric and can include Placeholder “X” as applicable.

4. Once the diagnoses have been completed, the form should be signed by your coder such as MDS Coordinator and/or Medical Records and therapy treatment diagnoses should be signed off by Therapy Program Director.

5. At the beginning of each month, prior to Medicare billing for the previous month, the team should complete Triple Check pre-billing audit to ensure that proper principal diagnosis is First-listed in MDS I8000/I0020B and FL 69/67 on the UB-04 and all other secondary diagnoses are listed as well including therapy treatment diagnoses if applicable both in I8000 and FL 67A-Q. ** (Please see Triple Check Form and Procedure) **

Diagnosis Codes on the UB-04:

1. List all appropriate diagnoses for the stay. The UB-04 form can accommodate up to 18 but only eight are seen on the electronic file. If the resident is receiving therapy, you need to include the therapy treatment diagnosis codes from the therapy plan of treatment (POT).

2. The reporting of the decimal between the third and fourth digit is unnecessary because it is implied. 3. Where the proper code has fewer than seven characters, do not fill with zeros.

Developed by Polaris Group (12.18) www.polaris‐group.com


PDPM SNF Primary Diagnosis/Surgical Procedure Crosswalk

MDS Item I0020B (Primary SNF Diagnosis) will be used to classify a patient into a PDPM clinical category when Item I0020 is coded as any response 01-13 listed below.

“RETURN TO PROVIDER” – codes are not deemed appropriate to enter as the primary reason for SNF care. Such codes either lack certainty and specificity required to properly categorize a resident under PDPM or the underlying condition cannot be the main reason of care in SNFs.

MDS Sections I0020/ I0100-I7900

Code Description ICD-10 Codes PDPM CategoryPT/OT

Category ST Category

Code 01 Stroke

I4500 checked

I8000

Ischemic stroke Cerebral vascular accident (CVA) Other cerebrovascular disease

I69.30 I69.90 I69.998

Acute Neuro Non-Ortho Surg/Acute Neuro

Acute Neuro

Subarachnoid hemorrhage I69.90 Med Mgmt Med Mgmt Non-Neuro

Code 02 Non-Traumatic Brain

Dysfunction/ I4200 I4800 I0100 I8000

Alzheimer’s disease Dementia with or without

behavioral disturbance

G30.0-G30.9 F02.81/F02.80


Acute Neuro

Malignant neoplasm of brain C71.0-C71.9 Cancer Med Mgmt Non-Neuro

Anoxic brain damage G93.1 Return to Provider

Code 03 Traumatic Brain

Dysfunction/ I5500 I8000

Traumatic brain injury Severe concussion Cerebral laceration and contusion

S06.9X0-S06.9X9 S06.2X0-S06.2X9 S06.300-S06.309 S06.380-S06.389 S06.0X0-S06.0X9 S06.310-S06.319 S06.320-S06.329 S06.330-S06.339 (All S06.3- codes require 7th character A, D, or S)

Acute Neuro Return to Provider (S06.0X0D)

Non-Ortho Surg/Acute Neuro

Acute Neuro

Code 04 Non-Traumatic Spinal

Cord Dysfunction/ I8000

Spondylosis with myelopathy

Transverse myelitis

M47.10-M47.16 G37.3

Non-surg Ortho/MS Acute Neuro

Other Ortho/ Non-Ortho Surg/Acute Neuro

Non-Neuro/Acute Neuro

Spinal cord lesion due to spinal stenosis

Spinal cord lesion due to dissection of aorta

G95.9 G95.9


Acute Neuro








Code 05 Traumatic Spinal Cord

Dysfunction/ I5000 I5100

Paraplegia following trauma Current injury- code to injury with 7th character A Sequela of previous injury – code to injury with 7th character S

Acute Neurologic for 7th character A or D, Med Mgmt for S

Acute Neuro or Med Mgmt

Acute Neuro or Non-Neuro

Quadriplegia following trauma Code to injury with 7th character S Current episode – see injury, spinal (cord), cervical (S14.109 – S14.158)

Acute Neurologic for 7th character A or D, Med Mgmt for S

Acute Neuro or Med Mgmt

Acute Neuro or Non-Neuro

Code 06 Progressive Neurological Conditions/

I5200 I5300

Multiple sclerosis Parkinson’s disease

G35 G20

Acute Neurologic Non-Ortho Surg/Acute Neuro

Acute Neuro

Code 07 Other Neurological

Conditions/ I4400 I8000 I2900

Cerebral palsy Myasthenia gravis Polyneuropathy

G80.1-G80.9 G70.00 -G70.01 G62.9, G62.1, [G63], G62.2, G62.81, G61.81, G62.0, G60.9, G60.8, G60.3, due to – many other codes

Acute Neurologic Non-Ortho Surg/Acute Neuro

Acute Neuro

Due to Diabetes E85.1 E85.1 Non-Surgical Orthopedic/ Musculoskeletal (E85.1)

Other Ortho Non-Neuro








Code 08 Amputation/

I8000

Acquired absence of limb Z89.9, Z89.619, Z89.51-, Z89.2-

Return to Provider

Code 09 Hip and Knee Replacement/

I8000

Total knee/hip replacement If hip replacement is secondary

to hip fracture, code as fracture

Z47.1 (This code would be followed by the Z96.60-Z96.698 to specify what joint)


Major Joint Replace or Spinal Surgery

Non-Neuro

Code 10 Fractures and Other

Multiple Trauma

Hip fracture S72.001- to S72.92X 7th character: A-C K-S

Non-Surg Ortho/MS Other Ortho Non-Neuro

D-J Ortho Surgery (Except Major Joint Replacement or Spinal Surgery)


Fracture of tibia and fibula S82.201- to S82.839- 7th character: A-C K-S


D-J Ortho Surgery (Except Major Joint Replacement or Spinal Surgery)


S89.001-S89.199 7th character: A, K, P, S









Code 10 Fractures and Other

Multiple Trauma, continued

D, G Ortho Surgery (Except Major Joint Replacement or Spinal Surgery)


Unspecified laterality codes in S89

Return to Provider

Pelvic fracture S32.10XA – S32.110B Non-Surg Ortho/MS Other Ortho Non-Neuro

S32.11D – S32.110G Ortho Surgery (Except Major Joint Replacement or Spinal Surgery)


S32.110K – S32.11B Non-Surg Ortho/MS Other Ortho Non-Neuro

S32.111, S32.112, S32.119 7th character: A, B K, S


D, G Ortho Surgery (Except Major Joint Replacement or Spinal Surgery)


Code 11 Other Orthopedic

Conditions

Unspecified disorders of joint M25.9 Return to Provider

Code 12 Debility,

Cardiorespiratory Conditions

Chronic obstructive pulmonary disease (COPD)

asthma

J44.0-J44.9 J45.20-J45.99

Pulmonary Med Mgmt Non-Neuro

other malaise and fatigue R53.81, Other malaise R53.83, Other fatigue

Return to Provider








Code 13 Medically Complex

Conditions

diabetes

E08 Codes E09 – E13

Return to Provider Med Mgmt

Med Mgmt

Non-Neuro

Pneumonia J18.9, J11-, J85.1, A or B code, J12.-, J18.-, J82, J15.-, J69.-J95.4, J84.89, J13.-, J14.-, J68.-,

Pulmonary Med Mgmt Non-Neuro

Chronic kidney disease N18.1-N18.9 Med Mgmt Med Mgmt Non-Neuro

Open wounds T14.8 or other S or T code

Med Mgmt Med Mgmt Non-Neuro

Pressure ulcer/injury L89.- Med Mgmt Med Mgmt Non-Neuro

Infection A00.- -B99.- Usually Acute Infection but could be Acute Neuro, Non-Surg Ortho/MS, Pulmonary, Med Mgmt, or Cardiovascular and Coagulations depending on the code

Usually Med Mgmt. Could be Non-Ortho Surg/Acute Neuro or Other Ortho

Non-Neuro or Acute Neuro

Disorders of fluid, electrolyte, and acid-base balance

E87.8, E87.4 Med Mgmt Med Mgmt Non-Neuro








Code 14 Other Medical

Condition

If the resident’s primary medical condition category is not one of the listed categories, check here.

Enter the International Classification of Diseases (ICD) code, including the decimal, in I0200A.

If item I0020 is coded 1-13, do not complete I0020A.


Developed by Polaris Group

Section J2100 – J5000 Patient Surgical History

Section J2100 – J5000 will capture surgical information which may be relevant to classifying the patient into a PDPM clinical category. These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission, i.e., the qualifying hospital stay. These items will be used, in conjunction with the diagnosis code captured in I0020B, to classify patients into the PT and OT case-mix classification groups for PDPM. Similar to the active diagnoses captured in Section I, these Section J items will be in the form of check-boxes.

Item Surgical Procedure Category

J2100 Recent Surgery Requiring Active SNF Care

J2300 Knee Replacement – partial or total

J2310 Hip Replacement – partial or total

J2320 Ankle Replacement – partial or total

J2330 Shoulder Replacement – partial or total

J2400 Spinal surgery – spinal cord or major spinal nerves

J2410 Spinal surgery – fusion of spinal bones

J2420 Spinal surgery – lamina, discs, or facets

J2499 Spinal surgery – other

J2500 Ortho surgery – repair fractures of shoulder or arm

J2510 Ortho surgery – repair fractures of pelvis, hip, leg, knee, or ankle

J2520 Ortho surgery – repair but not joints

J2530 Ortho surgery – repair other bones

J2599 Ortho surgery – other

J2600 Neuro surgery – brain, surrounding tissue or blood vessels

J2610 Neuro surgery – peripheral and autonomic nervous system – open and percutaneous

J2620 Neuro surgery – insertion or removal of spinal and brain neurostimulators, electrodes, catheters, and CSF drainage devices

J2699 Neuro surgery – Other

J2700 Cardiopulmonary surgery – heart or major blood vessels – open and percutaneous procedures

J2710 Cardiopulmonary surgery – respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords – open and endoscopic

J2799 Cardiopulmonary surgery – Other

J2800 Genitourinary surgery – male or female organs

J2810 Genitourinary surgery – the kidneys, ureter, adrenals, and bladder – open, laparoscopic


Developed by Polaris Group

Item Surgical Procedure Category

J2899 Other major genitourinary surgery

J2900 Major surgery – tendons, ligament, or muscles

J2910 Major surgery – the GI tract and abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver, pancreas, spleen – open or laparoscopic

J2920 Major surgery – endocrine organs (such as thyroid, parathyroid) neck, lymph nodes, and thymus – open

J2930 Major surgery – the breast

J2940 Major surgery – repair of deep ulcers, internal brachytherapy, bone marrow, or stem cell harvest or transplant

J5000 Major surgery – Other not listed above


ICD‐10‐CM SNF Quick Reference

General Info

Resources for Coding:

In order of priority or precedence: 1. ICD‐10‐CM code set

2. Official Coding Guidelines 3. Coding Clinic (requires subscription)

Websites: • CDC http://www.cdc.gov/nchs/icd/icd10cm.htm

• CMS https://www.cms.gov/Medicare/Coding/ICD10/2019‐ICD‐10‐CM.html

• ICD‐10‐CM Codes http://www.icd10data.com

• AHIMA http://www.ahima.org/icd10

• CMS lookup tool that allows users to search for codes by ICD‐10 description keywords:https://www.cms.gov/medicare‐coverage‐database/staticpages/icd‐10‐code‐lookup.aspx

Format/Steps to Coding

ICD‐10‐CM Format Two main parts:

The Index ‐ alphabetical list of terms and their corresponding code.

Tabular List ‐ sequential, alphanumeric list of codes divided into chapters based on body system or condition.

Steps to Coding: (Process is not

new)

1. First locate term in the Alphabetic Index

2. Then verify in the Tabular List 3. Read and be guided by instructional notations that appear in both 4. Essential to use both Alphabetic Index and Tabular List 5. Alphabetic Index does not always provide the full code 6. Selection of the full code, including laterality and any applicable 7th

character can only be done in the Tabular List.


2Provided by Polaris Group www.polaris‐group.com


Admit/Principal/Additional Diagnoses

Admitting Diagnosis (UB‐04 Field locator 69)

• Condition established after study to be chiefly responsible for the admission.

Principal/Primary Diagnosis (UB‐04 Field locator 67)

• Condition chiefly responsible for the resident’s admission to SNFor reason for continued SNF care.

• Frequently matches Admitting Diagnosis – Field 69

Additional Diagnoses (UB‐04 Field locator 67 A‐Q)

• Additional conditions coexisting at the time of admission which developed subsequently, and which had an effect upon the treatment given for the length of stay.

Abbreviations and Terms

NEC • Not Elsewhere Classifiable

NOS • Not Otherwise Specified

[ ] Brackets • Tabular List ‐ encloses synonyms, alternative wording or explanatory phrases.

• Alphabetic Index ‐ identifies manifestation codes.

( ) Parentheses • Alphabetic Index ‐ nonessential modifiers that apply to subterms following a main term except when a nonessential modifier is mutually exclusive, the subentry takes precedence.

: Colon • Tabular List after an incomplete term which needs one or more of the

modifiers following the colon to make it assignable to a given category.

“Other” • Used when the information in the medical record provides detail for

which a specific code does not exist.

• Alphabetic Index entries with NEC in the line designate “other” codes in

the Tabular List.

• Alphabetic Index entries represent specific diseases where no specific code exists so it is included within an “other” code.





“Unspecified” • Use when the information in the medical record is insufficient to assign

a more specific code.

• For those categories for which an unspecified code is not provided, the “other specified” code may represent both other and unspecified.

Includes Notes • Appears immediately under a three‐character code title to further define,

or give examples of, the content of the category.

Inclusion Terms • List of terms that give conditions for when that code is to be used.

• May be synonyms of the code title, or, in the case of “other specified” codes, the terms are a list of the various conditions assigned to that code.

• Not necessarily exhaustive.

Excludes1 • “NOT CODED HERE!”

• A type 1 Excludes note is a pure excludes note.

• Indicates that the code excluded should never be used at the same time as the code above the Excludes1 note.

• The two terms are mutually exclusive, so they would never be used together.

Excludes2 • “NOT INCLUDED HERE!”

• Indicates although the excluded condition is not part of the condition it is excluded from, a patient may have both conditions at the same time.

• May be acceptable to use both the code and the excluded code

together if supported by medical record documentation.

“Code First” and “Use Original Code”

• Also used as sequencing rules in the classification for certain codes that

are not part of an etiology/manifestation combination.

“And” • Means either “and” or “or” when it appears in a title.

“With” 2019 Update: Added under main term or subterm

• The word “with” or “in” means “associated with” or “due to” when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List.

• The classification presumes a causal relationship between the two conditions linked by these terms.





“See” • Alphabetic Index ‐ follows a main term indicating that another term

should be referenced.

• It is necessary to go to the main term referenced with the “see” note to locate the correct code.

“See Also” • Alphabetic Index – follows a main term instructing that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful.

• Not necessary to follow the “see also” note when the original main term provides the necessary code.

“Code Also Note” • Two codes may be required to fully describe a condition, but this note does not provide sequencing direction.

• The sequencing depends on the circumstances of the encounter.

Placeholder X • Placeholder for future expansion.

• Where a placeholder exists, the “X” must be used in order for the code

to be valid.

• Example: T36.0X1 Poisoning by penicillin, accidental

7th Characters • Use 7th characters as applicable. Common with fracture codes to

specify initial, subsequent, or sequela care.

• The 7th character must always remain the 7th character.

• If a code that requires a 7th character is not six characters, a

placeholder X must be used to fill in the empty characters.

Combination Codes • Used to classify two diagnoses or diagnosis with manifestation or complication

• Must use combination code when it fully describes a condition.

Otherwise use multiple codes to fully describe.

Default Codes • Listed next to a main term in the Alphabetic Index.

• Condition that is most commonly associated with the main term, so if

more detail is not provided or can’t be determined from physician, use

default code.

Default Code Example • Appendicitis (pneumococcal) (retrocecal) K37 – (K37 is the

default code for Appendicitis)





Acute and Chronic Conditions

• If resident has both acute and chronic for same diagnosis or condition,

code both, and code acute before chronic.

Sequela • A sequela is the residual effect (condition produced) after the acute

phase of an illness or injury has terminated.

• There is no time limit on when a sequela code can be used.

• Generally, requires two codes sequenced in the following order:

o The condition or nature of the sequela is sequenced first. o The sequela code is sequenced second.

• An exception would be those instances where the code for the sequela is followed by a manifestation code or the sequela code has been expanded to include the manifestation(s).

• Never use the code for the acute phase of an illness or injury that led to

the sequela with a code for the late effects.

Chapter Specific Guidelines

Diabetes Mellitus • Combination codes that include:

– type of diabetes mellitus

– body system affected

– complications affecting that body system

• Use as many codes from this category as necessary to fully describe all the complications of the disease.

• If the type of diabetes mellitus is not documented, the default is E11.‐, Type 2 diabetes mellitus.

• If the patient is treated with insulin or both oral medications and insulin, only the code for long‐term (current) use of insulin should be assigned, Z79.4, Long‐term (current) use of insulin.

Dominant/Non‐ Dominant Side

• If the affected side is documented but not specified as dominant or non‐dominant, and classification system does not indicate a default, code as follows:

– For ambidextrous residents, the default should be dominant.

– If the left side is affected, the default is non‐dominant.

– If the right side is affected, the default is dominant.




Chapter Specific Guidelines

Glaucoma • Assign as many codes from category H40, Glaucoma, as needed to identify:

– type of glaucoma

– the affected eye

– the glaucoma stage

• Many bilateral codes for glaucoma.

Pressure Ulcers (Category L89)

• Combination codes that identify the site of the pressure ulcer (including

laterality) as well as the stage of the ulcer.

Z codes • Z Codes are not used like the prior V codes were for Rehab.

• No ability to use a Z code for multiple therapies as Principal/First‐ listed diagnosis.

• Underlying diagnosis would be listed first

• Continue to use therapy treatment diagnosis

Aftercare Z Codes Related To Fractures

• Assign the acute fracture code with the appropriate 7th character for

subsequent encounter during healing recovery phase such as:

– “D” for Subsequent (aftercare) or

– “S” for Sequela (complications or late effects)

Hip Replacement following fracture

2018 Update:

• Code the injury (fracture) as the first‐listed primary diagnosis NOT the hip

replacement followed by the Z96.6xx code to indicate what joint was

replaced.




ICD-10-CM Common Coding Errors Specificity

• All codes need to be taken to the greatest specificity possible.

• Codes not taken to the greatest specificity (number of characters)

supported by medical record are considered invalid.

• Codes can be 3 to 7 characters depending on the circumstance.

Laterality • Allows you to specify left, right, or bilateral.

• If no bilateral code provided, code both left and right as separate codes.

• Common bilateral codes include pressure ulcers, fractures, and eye

conditions such as glaucoma.

• Most conditions use a fifth or sixth character of “1” – Right, “2” – Left “9” –

Unspecified.

• If “unspecified” in the record, make every effort to find out the correct

extremity or location of the condition.

Etiology/ Manifestation Codes

• Underlying condition (etiology) should be coded first followed by the

manifestation code.

• Manifestation codes cannot be first‐listed or principal diagnosis codes.

• Use combination code if it includes both etiology and manifestation.

Seventh Characters

• “D” as the seventh character designates subsequent care of a healing

fracture. The acute care setting uses an initial encounter code such as “A”

and this usually must be changed to a subsequent encounter code such as

“D” in the Long‐Term Care setting.

• “S” as the seventh character designates “sequela.” (late effects). When

using both the injury code and the sequela code, the sequela code is first,

followed by the injury code with a seventh character “S”. List First: L90.5, Scar conditions and fibrosis of skin Followed By: T23.301S, Burn of third degree of Rt hand, unspecified site, sequela

Z Codes • Aftercare Z Codes: When used, they are generally listed first as principal diagnosis to explain a reason for an encounter.

• Aftercare Z Codes are NEVER used for traumatic injuries. Instead, an acute injury code is used with the seventh character “D” which designates a subsequent encounter for a healing injury.

• Aftercare Z Codes are not used if treatment is directed at a current acute disease.




ICD-10-CM Common Coding Errors Cerebrovascular

Disease • The code for the acute phase of an illness or injury that led to the sequela is

never used with a code for the late effects. • Codes I60 – I67 are used for the acute phase of an illness and are NEVER

used in the Post-Acute Setting. • The I69 codes for Sequela (Late Effects) of Cerebrovascular Disease are

used in LTC and require six characters to be valid, and therefore billed.

Acute Conditions • Any acute condition treated at the hospital that continues to require follow up or ongoing monitoring should be coded with an acute diagnosis code as long as the condition persists and requires follow up.

• Otherwise, code the appropriate Z code for aftercare.

Pain • A code from category G89 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control/ management and not management of the underlying condition.

• Expected post-operative pain should not be coded.




ICD-10-CM Common Coding Errors

Codes That Should Not Be Used as

Principal Diagnosis

• Z51.89: “Encounter for Other Specified Aftercare” should NEVER be used as a replacement for V57.xx in ICD-10.

• Organisms: If the infection itself does not include the organism, then the infection itself should be coded first, followed by the organism if known.

o An instructional note will be found at the infection code advising that an additional organism code is required.

o Example: Z16.xxx: “Resistance to Antimicrobial Drugs” should not be used as a principal diagnosis.

o Code the infection first. N39.0 Urinary Tract Infection, must be followed by the code for the organism if known.

• Status Z Codes: Status Z codes would not be listed as the principal, first-listed diagnosis.

o Status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare. Example: Z93.1 – Gastrostomy Status.

• Presence of Z Codes: (Z96.xxx) are not used as principal diagnosis. Either Z47 would be first-listed if aftercare for orthopedic procedure or in the case of an injury the acute injury code would be first, like S72.xxxD, for a fracture. Example: Z96.642 – Presence of left artificial hip joint

• History Z Codes: Should not be used as principal diagnosis. However, history codes may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

• Manifestation Codes: Manifestation Codes cannot be the principal diagnosis. A manifestation is a condition that is an extension of the primary (underlying) illness in question. Example: neuropathy is a manifestation of diabetes, or is caused by the diabetes, so if not for the diabetes, the neuropathy could not “manifest”. Sequence the primary illness first because the secondary condition would not be present without the existence of the primary underlying condition.

• External Cause Codes: (V, W, X, Y) These codes describe the circumstances causing an injury, not the nature of the injury itself, and therefore should not be used as a principal diagnosis. The injury itself should be primary diagnosis.

• Therapy Treatment Codes: Therapy treatment codes (Example: M62.81 Muscle Weakness) support the provision of therapy but are not used as principal diagnosis. Instead the condition that is causing these symptoms and the need for therapy should be the principal diagnosis.

• R00 – R99 Codes: Symptoms, Signs and Ill-Defined Conditions are not used as Principal Diagnosis, when a related definitive diagnosis has been established. These include some of the therapy treatment codes like R26.2, Difficulty Walking.


ICD-10-CM MDS I8000 Crosswalk

Please note that this crosswalk in no way replaces following steps for coding including looking up code first in Alphabetic Index and then verifying code in Tabular List following all instructions, notes, etc. and using all characters required for that code. Crosswalk just provides possible code categories as a point of reference.

Dash = Additional characters may be required

***Remember that I8000 also requires additional active diagnoses that are not listed in check off section (I0100-I7900). First-listed I8000 should match I0020B (primary reason for admission) and all active diagnoses need to be listed as additional to capture all comorbidities for NTA/SLP for Patient-Driven Payment Model.*** MDS Section Diagnosis Description ICD‐10‐CM Code(s)

I0100 Cancer C00 – D49

I0200 Anemia D50.8‐ , D50.9‐, D51.0‐, D57.‐, D60.‐, D61.9‐

I0300 A‐Fib/Other Dysrhythmias I48.‐, I49.‐, R00.‐, I47.‐

I0400 Coronary Artery Disease (CAD) I25.‐

Angina I20.0‐ ‐I20.9‐

MI I21.‐, I22.‐

ASHD 125.‐

I0500 Deep Venous Thrombosis (DVT) I82.‐

Pulmonary Embolism (PE) I26.‐, I27.‐

Pulmonary Thrombo‐Embolism (PTE) I26.‐, I27.‐

I0600 Heart Failure I50.‐

Pulmonary Edema J81.‐

I0700 Hypertension I10 (Default Code) and many chapters involved depending what its combined with I11.‐, I12.‐, I13.‐

I0800 Orthostatic Hypotension I95.‐

I0900 Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD) I73.9 (more detail probably not needed)

I1100 Cirrhosis K74.‐, K70.‐, or another chapter

I1200 GERD or Ulcer K21.9

Esophageal Ulcer K21.‐, K22.‐

Gastric Ulcer K25.‐

Peptic Ulcer K27.‐

I1300 Ulcerative Colitis K51.‐

Crohn’s Disease K50.‐

Inflammatory Bowel Disease K50.‐ ‐K52.‐

I1400 Benign Prostatic Hyperplasia (BPH) N40.0‐N40.1

I1500 Renal Insufficiency

Acute N28.9

Chronic N18.9

Renal Failure N19.‐, N17.‐, N18.‐

End‐Stage Renal Disease (ESRD) N18.6



MDS Section Diagnosis Description ICD‐10‐CM Code(s)

I1550 Neurogenic Bladder N31.9 (more detail probably not needed)

I1650 Obstructive Uropathy N13.9, N13.8

I1700 Multidrug‐Resistant Organism (MDRO) Z16.‐

I2000 Pneumonia J18.9 (Default Code) or other J, A, or B code

I2100 Septicemia (Sepsis) A41.9 or many other codes

I2200 Tuberculosis A15.9 or other A or J codes

I2300 UTI N39.0 or other codes

I2400 Viral Hepatitis A, B, C, D, & E) B19.9 or other B code

I2500 Wound Infection Many codes

I2900 Diabetes Mellitus E11.9 or other E code

Diabetic Retinopathy E11.3‐ or other E code

Diabetic Nephropathy E11.21‐ or other E code

Diabetic Neuropathy E11.4‐ or other E code

I3100 Hyponatremia E87.1 (more detail probably not needed)

I3200 Hyperkalemia E87.5 (more detail probably not needed)

I3300 Hyperlipidemia/Hypercholesterolemia E78.5, E78.‐

I3400 Thyroid Disorder

Hypothyroidism E03.‐, E02.‐, E89.‐

Hyperthyroidism E05.‐

Hashimoto’s Thyroiditis E06.3

I3700 Arthritis/DJD/Osteoarthritis M19.‐, M15.‐, M16.‐, M17.‐, M18.‐

Rheumatoid Arthritis M06.9, M08.‐, M06.‐, M05.‐

I3800 Osteoporosis M80.‐, M81.‐

I3900 Hip Fracture (traumatic or pathological) S72.‐, S79.‐, M84.‐, M97.‐

I4000 Other Fracture S or M code

I4200 Alzheimer’s Disease G30.‐

I4300 Aphasia R47.01, F80.2, F80.‐, I69.‐, G31.01

I4400 Cerebral Palsy G80.‐

I4500 CVA I69.‐

I4800 Non‐Alzheimer’s Dementia



MDS Section Diagnosis Description ICD‐10‐CM Code(s)

Lewy Body Dementia G31.‐

Vascular Dementia F01.‐

Pick’s G31.‐

Pick’s with Parkinson’s G31.‐

Pick’s with Creutzfeldt‐Jakob Disease A81.00

I4900 Hemiplegia or Hemiparesis G81.‐, G83.‐, I69.‐

I5000 Paraplegia G82.‐, G80.‐, G11.‐, F44.‐, A18.‐, A52.‐, G04.‐

I5100 Quadriplegia G82.5‐

I5200 Multiple Sclerosis (MS) G35 (more detail not needed)

I5250 Huntington’s Disease G10 (more detail not needed)

I5300 Parkinson’s Disease G20 (more detail not needed)

I5350 Tourette’s Syndrome F95.2 (more detail not needed)

I5400 Seizure Disorder or Epilepsy G40.‐, or other codes

I5500 Traumatic Brain Injury (TBI) S06.‐

I5600 Malnutrition E46.‐, E44.‐, E43.‐, E42.‐, K91.‐, E40.‐, E41.‐

I5700 Anxiety Disorder F41.‐, F10.‐, F15.‐, F13.‐, F12.‐, F14.‐, F06.‐, F16.‐, F18.‐, F19.‐, F40.‐

I5800 Depression F32.‐, F41.‐, F44.‐, F34.‐, F33.‐

I5900 Manic Depression F31.‐

I5950 Psychotic Disorder F29.‐ or many other codes

I6000 Schizophrenia F20.‐, F23.‐, F21.‐, F25.‐, F32.‐

I6100 Post Traumatic Stress Disorder (PTSD) F43.‐

I6200 Asthma, COPD, Chronic Lung Disease J45.‐, J44.‐, or many other codes, J42.‐,

Asbestosis J61

I6300 Respiratory Failure J96.‐, J95.‐

I6500 Cataracts H26.9, Q12.‐ or many other codes

Glaucoma H40.‐, H42.‐, H44.‐, Q15.‐, or other code

Macular Degeneration H35.‐


Documents

ICD-10-CM Impact on PDPMICD-10-CM Impact on PDPM POST TEST ANSWERS 1. The care team needs to identify and sequence all codes in I8000 including first-listed primary reason for admission