ICD-10-CM AND THE PDPM - paanac.net and PDPM.pdf · Factors which impact ICD-10-CM code assignment Information provided from acute care –ranges from nothing to volumes of paper/information

ICD-10-CM AND

THE PDPMMary Ann P. Leonard, RHIA, RAC-CT

Health Information Professionals

[email protected]

ICD-10-CM AND THE PDPM

OBJECTIVES

■ To understand how the ICD-10-CM codes are utilized by the

new payment system

■ To understand how the Clinical Category Mapping is utilized

■ To understand in which ‘buckets’ of the PDPM the diagnostic

code is being used

■ To provide recommendations related to the best utilization

of the ICD-10-CM codes

Health Information Professionals 2


ICD-10-CM SOURCE



Where does the International Classification of Disease, Clinical

Modification (ICD-10-CM) come from?

■ Developed through the World Health Organization

■ Adopted by countries around the globe

■ Adapted for the needs of the specific country

■ Utilized to gather information/statistics on diseases

■ Beta testing for ICD-11-CM has been completed



Sources for criteria for assigning the ICD-10-CM codes

■ Coding Guidelines published by CDC, DHHS/CMS

■ Coding Clinic published by the American Hospital

Association

– Managed by the Cooperating Parties – American

Hospital Association, American Health Information

Association, National Center for Health Statistics,

Centers for Medicare/Medicaid Services

– Question and answer format, questions/situations

submitted by multiple sources



What was the impact of ICD-10-CM in the past?

■ ICD-10-CM codes were not utilized under RUGs as a direct

impact on reimbursement

■ Diagnoses which impacted RUGs were primarily check-offs

in section I, e.g. hemiplegia, Diabetes Mellitus or

incorporated in other section of the MDS e.g. Section O for

trach/vent care

■ Under PDPM there is a direct relationship between the code

assignment and payment categories



Factors which impact ICD-10-CM code assignment

■ Information provided from acute care – ranges from nothing

to volumes of paper/information (some provide EHR portals)

■ Can only use diagnoses documented by a provider

(physician, nurse practitioner or physician assistant)

■ Lack of specificity from the provider e.g. hip fracture,

pneumonia, stroke, DM, HTN, etc.

■ Lack of clarity re: the principal or primary diagnosis

■ Culture of therapy seen as the driving force for skilled care


POLICY AND PROCEDURE

Every facility should have a policy/procedure on diagnostic code assignment

Some items to be addressed are, but not limited to,

–Following the Coding Guidelines

–What diagnoses are to be used

–Timeframe for coding

–Documentation sources for the diagnoses

–Querying of the Provider

8

CODING WITH ICD-10-CM AND THE MDS (ACCORDING TO THE PA RAI

COORDINATOR)

Coding diagnoses in Section I is not based on ICD codes.

Alzheimer's, Huntingdon's, and Parkinson’s disease each have a

corresponding item on the MDS, and would be coded if the criteria stated

in the RAI User’s Manual are met.

The basics of coding a diagnosis include:

■ The disease conditions in Section I require a physician documented

diagnosis in the resident's medical record such as in: physician progress

notes, recent history and physical, recent discharge summaries,

medication sheets, doctor’s orders, consults and official diagnostic reports.

■ If a diagnosis/problem list is used, only diagnoses confirmed by the

physician should be entered.

CODING WITH ICD-10-CM AND THE MDS

Coding diagnoses in Section I is not based on ICD codes (cont.)

■ Diagnoses communicated verbally must be documented in the medical record by the

physician to ensure follow-up.

■ Diagnostic information, including past history obtained from family members and close

contacts, must also be documented in the medical record by the physician to ensure

validity and follow-up.

■ 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.

■ Conditions that have been resolved, do not affect the resident’s current status, or do not

drive the Resident’s plan of care during the 7-day look-back period, are considered inactive

diagnoses, and are not coded on the MDS.

Pennsylvania RAI Coordinator


Some coding rules which directly impact SNF code assignment

■ Diagnoses must be documented by the provider within the last 60 days ( of the ARD) and active within the last 7 days (RAI Manual)

■ Infections which were treated in the hospital and treatment is completed before they arrive at the SNF, the infection cannot be coded (e.g. UTI, Pneumonia, Sepsis, etc.)

■ Long term residents who return after a hospital admission must be coded to the reason why they are long term (e.gAlzheimer's, dementia, Parkinson's, MS, CVA with sequela, etc.)



Some coding rules which directly impact SNF code assignment

■ Use of 7th character to identify the episode of care still

applies

– A – initial (acute) episode of care (diagnostic)

– D – subsequent episode of care (treatment)

– S – sequela episode of care (residual from previous

injury or trauma

■ Stroke related codes are I69 not I63, etc.



Some implications with the Clinical Category Mapping

■ Most rehab codes will not be accepted as the primary

diagnosis – “Return to Provider”

■ Lack of specificity in code assignment could generate a

“Return to Provider” response

■ Secondary diagnoses will impact the final payment through

the Non Therapy Ancillaries (NTA) points, e.g. transplant,

morbid obesity, MS, CP, COPD, DM, etc.

■ The ICD-10-CM code must appear in I8000, if not a check-

off, in order to receive the designated point/s



Some diagnostic codes which are “Return to Provider” when primary (under a recent vendor study “Return to Provider” codes were @ 10% of the primary diagnoses)

■ M62.81 Muscle weakness

■ Z87.01 Personal History of pneumonia

■ Z51.81 Encounter for other specified aftercare

■ Z48.89 Encounter for other specified surgical aftercare

■ S82.486D Nondisplaced transverse fracture of shaft of

unspecified fibula, routine healing

■ R62.7 Adult failure to thrive

■ R53.1 Weakness



Some diagnostic codes which are “Return to Provider” when primary

■ R53.2 Functional quadriplegia

■ R53.81 Malaise

■ R54 Age related debility

■ R41.82 Altered mental status

■ R41.81 Age related cognitive decline

■ R29.6 Repeated falls

■ R27.9 Unspecified lack of coordination



Some diagnostic codes which are “Return to Provider” when primary

■ R26.9 Unspecified abnormalities of gait

■ R13.--- Dysphagia (all phases)

■ I69.369 Other paralytic syndrome following cerebral

infarction affecting unspecified side

■ I69.359 Hemiplegia and hemiparesis following cerebral

infarction affecting unspecified side

■ K92.2 Gastrointestinal hemorrhage, unspecified



Some diagnostic codes which are “Medical Management” or

“Acute Neurologic” when primary

■ R26.0 Ataxic gait

■ R26.1 Paralytic gait

■ R26.89 Other abnormalities of gait and mobility

(Nonsurgical orthopedic/Musculoskeltal)

■ R27.0 Ataxia, unspecified

■ R27.8 Other lack of coordination

■ R29.1 Meningismus





■ R29.818 Other symptoms and signs involving the

nervous system

■ R29.898 Other symptoms and signs involving the

musculoskeletal system

■ R40.3 Persistent vegetative state

■ R41.44 Neurologic neglect syndrome

■ R41.842 Visuospatial deficit





■ R47.01 Aphasia

■ R47.02 Dysphasia

■ R47.1 Dysarthria and anarthria

■ R47.89 Other speech disturbances

■ R48.2 Apraxia

■ R53.0 Neoplastic (malignant) related fatigue



Five mistakes often made selecting ICD-10-CM codes in the

SNF

■ Using unspecified codes

■ Coding resolved diagnoses

■ Incorrect 7th character

■ Coding from the internet, a cheat sheet or facility software

■ Coding a diagnosis that was not documented by a Provider

SOURCE: Jessie McGill, AANAC newsletter



Other mistakes often made selecting ICD-10-CM codes in the

SNF

■ Using multiple single codes when a one i.e. a “combination

code”, will do (acute on chronic codes) e.g. acute on chronic

heart failure

■ Using hospital based diagnoses without having the current

provider reviewing

■ Using an aftercare code when not appropriate – aftercare of

surgery not injury; encounter for other specified hospital

aftercare



Some common diagnoses which need additional information:

■MCA or CVA (any residuals? What, if any?)

■MCA or CVA with hemiplegia (left side? Right side?

Dominant? Non-dominant?)

■Heart Failure or HF (type? Acute? Chronic? Associated

problems?

■Pneumonia (cause? Type?)

■DM (Type 1? Type2? Any related conditions eg. Retinopathy,

vascular related conditions? Skin related conditions?)



OVERVIEW OF

THE

PDPM STRUCTURE




MDS schedule

■ Calculations for PDPM payment are based on the

information contained in the 5-day MDS

■ Calculation would change only with the submission of an

Interim Patient Assessment (IPA) which reflects a change in

condition/category




PT/OT

■ Utilizes the diagnosis in I0020B to identify the Clinical Category

■ The resident’s Function Score is then identified which then leads to the case mix index and the associated weight factor

■ The CMI weight factor is then multiplied times the PT/OT daily payment to identify the final payment for each day

■ Note: the CMI weight factor and daily payment rate are different for PT and OT

■ After the 20th day, daily rate decreases by 2% every 7 days





IDENTIFY ICD-10-CM CODE

IDENTIFY FINAL

CLINICAL CATEGORY

IDENTIFY RESIDENT FUNCTION

SCORE

DETERMINE PDPM CMI

PT/OT under PDPM


ST

■ Acute neurologic or not

■ Utilizes the cognitive score – BIMS/CPS

■ Utilizes specific diagnoses (Speech Comorbidities), part

check-off, part ICD-10-CM

■ Mechanically soft diet or difficulty swallowing

■ CMI multiplied times the daily ST rate provides the daily ST

rate

■ Rate remains the same throughout the stay






IDENTIFY ICD-10-CM CODE

IDENTIFY FINAL CLINICAL

CATEGORY

IDENTIFY COGNITIVE

FUNCTION AND COMORBIDITIES

SWALLOWING DISORDER OR MECHANICAL

ALTERED DIET?

DETERMINE PDPM CMI

ST under PDPM


Nursing

■ Utilizes RUG categories however the number of terminal categories has been reduced from 43 to 21

■ Some diagnoses still impact the Nursing category assignment, e.g. Diabetes Mellitus, hemiplegia, Parkinson’s. etc. but pulled from the check-off

■ Function score will assist in determining the terminal category

■ Depression and Restorative Nursing still has an impact

■ CMI multiplied times the base rate for the daily rate


ICD-10-CM AND THE PDPM■ Nursing







Non Therapy Ancillaries

■ Top 50 diagnoses which consume the most resources

■ HIV pulled from the billing form (UB-04) NOT the MDS

■ Some are from various areas of the MDS including, but not limited to, Section I Diagnoses

■ Points added and determines the CMI

■ CMI multiplied times the base rate

■ Receives 3 times the daily rate for the first 3 days of the stay then return to the daily rate

■ Stars in the following grids – Yellow = diagnoses pulled from I8000; Orange = may need additional diagnostic codes














IDENTIFY ICD-10-CM

CODE

IDENTIFY IF INCLUDED IN NTA LISTING

IDENTIFY POINTS TO

BE ALLOTTED

DETERMINE PDPM CMI

NTA under PDPM



Bed and Board

Non Case Mix




CLINICAL

CATEGORY

MAPPING









DEFINING THE

DIAGNOSIS



■ Definitions of the various types of diagnoses were

established in the Universal Hospital Discharge Data Set

(UHDDS) (July 31, 1985; Federal Register)

■ Definitions apply to all health care organizations and levels

of care

■ Definitions can be found in the Coding Guidelines and

Medicare Benefit Policy Manual



PRINCIPAL DIAGNOSIS –

■ The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

■ Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc). The UHDDS definitions also apply to hospice services (all levels of care). (pg 107; ICD-10-CM Official Coding Guidelines for Coding and

Reporting)



OTHER DIAGNOSES

■ “all conditions that coexist at the time of admission, that

develop subsequently, or that affect the treatment received

and/or the length of stay. Diagnoses that relate to an earlier

episode which have no bearing on the current hospital stay

are to be excluded.” UHDDS definitions apply to inpatients in

acute care, short-term, long term care and psychiatric

hospital setting. ). (pg 107; ICD-10-CM Official Coding Guidelines for Coding and

Reporting)



PRIMARY DIAGNOSIS

■ First listed or that diagnosis to which the most resources are directed. In most cases the primary diagnosis is the same as the principal diagnosis but there may be circumstances when this may not be true

■ “It is important to note that this primary diagnosis represents the primary reason that the patient was admitted to the SNF which may or may not be the same reason that the patient was admitted to the qualifying hospital stay. In other words, there is no necessary reason that the primary SNF diagnosis must match the primary hospital diagnosis from the prior hospital stay. We would further note as illustrated in the ICD-10 crosswalk on the PDPM website, not all diagnoses are considered valid primary diagnoses for the SNF stay.” (pg 5, 12/11/18 SNF ODF Transcript)


■ Post-hospital extended care services furnished to inpatients of

a SNF or a swing bed hospital are covered under the hospital

insurance program.

■ In addition, the beneficiary must require SNF care for a

condition that was treated during the qualifying hospital stay,

or for a condition that arose while in the SNF for treatment of a

condition for which the beneficiary was previously treated in

the hospital.Medicare Benefit Policy Manual pg. 4




Determining the diagnosis

■ Must meet the criteria of the RAI Manual as well as the

Coding Guidelines

■ Must be documented by a provider (physician/nurse

practitioner/physician assistant) within the previous 60 days

■ Must be considered ‘active’ – diagnosis/es have a direct

relationship to the resident’s current functional, cognitive,

mood or behavior status, medical treatments, nursing

monitoring or risk of death during the look back period




Recommended code = I0020B but refer to Manual when available

Reflect comorbidities

for Speech Therapy

and Non Therapy

Ancillaries


Sources of the information

– Hospital information

– Transfer information

– History and physical

– Progress note/s

– Consult reports

– Surgical reports

– Diagnostic information e.g. labs, xrays, etc. can be used to assist in providing more specific diagnostic codes but NOT as the source of the diagnosis, e.g. UTI – lab identifies Ecoli bacteria



■ Primary reason for admission to be documented in I0020A

as a check off – used for the SNF QRP

■ Diagnostic code reflecting the reason for admission to be

documented in I0020B – used for the PDPM




Used for the SNFQRP

Used for PDPM


MDS 3.0 SECTIONS

EFFECTIVE 10/1/19

















ACCESSING THE

INFORMATION ON THE

CLINICAL CATEGORY

MAPPING SPREAD SHEET



■ Be sure to use the most current Clinical Category Mapping

tool (Excel spreadsheet)

■ Utilize the search tool to locate the code; test it for accuracy

■ Use just the alpha-numeric when entering the code in the

search tool, no decimal points

■ Know that the computer will be programmed to perform the

search, just as it does for RUGs now (PCC has already updated

the system to reflect these PDPM related changes)





Provider related

■ Educate Providers on the new system and the need for

accurate, complete diagnostic information as well as the

timeframe for the MDS ARD

■ Establish a procedure for querying Providers when there is

insufficient diagnostic information (requires a written policy)

■ Determine if the Providers see the residents within a timely

manner for capturing the needed information for the 5 day

MDS



■ Attend education on how to accurately code with ICD-10-CM

■ Utilize a current ICD-10-CM coding manual when assigning diagnostic codes

■ Adhere to the requirements of the Coding Guidelines and Coding Clinic

■ Review current procedure, source, timeliness of obtaining diagnoses

■ Review current process, timeliness and accuracy for assigning the ICD-10-CM diagnostic code/s

■ Develop a policy on the coding process



■ Review current codes and clean the lists

■ Determine the primary diagnosis as a team and/or team consensus TEAMWORK AND COMMUNCIATION IS CRITICAL

■ Ensure the ENTIRE team is educated to the parameters of PDPM – Admissions, Social Services, Nursing staff, Activities, Dietary

■ Implement a review process such as Triple Check

■ Consider implementing a Clinical Documentation Integrity (CDI) process in the facility

■ Make sure there is a back-up educated individual in the facility for assigning the diagnostic codes



■ Consider incorporating diagnosis review along with the

admission drug regimen review

■ Evaluate the setting of the Assessment Reference Date

(ARD) due to the availability of the diagnostic information

■ Determine the diagnosis assignment for an Interim Patient

Assessment (IPA)

■ Therapy codes can still be listed on I8000 but determine

which would be the most appropriate codes to be in I8000

as there are a limited number of lines available and the ST

and NTA code identification should take precedent



■ Obtain as much ‘final’ information from the hospital as possible

■ Contact the hospital Medical Records Department for additional information, if needed

■ Do not include resolved conditions

■ Include ‘history of’ codes that have an impact on the resident’s current status

■ Z codes CAN be included on I8000 however surgical Z codes should not be there as identification of surgical aspects are identified in section J



■ Code to the highest level of specificity, avoid unspecified

codes as much as possible

■ Practice the assignment of the PDPM case mix to determine

potential problem areas in the system

■ Identify the most frequent primary diagnoses assigned and

determine if they would successfully flow through the system

■ Determine the value of the information provided at the time

of admission and what additional types of information would

be beneficial if available at admission



PRACTICE EXAMPLE





CMS PDPM web page

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

Technical report

■ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html

CMS ICD-10-CM

■ https://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-CM.html

CODING PRACTICE BRIEFS

■ www.ahima.org (go to HIM Body Of Knowledge at bottom of page)


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

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

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

http://www.ahima.org/

Documents

ICD-10-CM AND THE PDPM - paanac.net and PDPM.pdf · Factors which impact ICD-10-CM code assignment Information provided from acute care –ranges from nothing to volumes of paper/information