REIMBURSEMENT AND ICD-10 CODING. December RB Health Partners, Inc.
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1 REIMBURSEMENT AND ICD-10 CODING December RB Health Partners, Inc.
2 Objectives
3 Objectives Ø Participants will learn Ø The role of diagnosis coding in the Patient Driven Payment Model (PDPM). Ø The importance of correct diagnosis identification and coding Ø The impact of diagnosis coding on the revenue cycle Ø How to prepare for increased importance of diagnosis coding with the implementation of PDPM
4 Diagnoses and PDPM
5 Patient-Driven Payment Model (PDPM) Overview PDPM uses clinical conditions to determine the resident s payment category, rather than the amount of therapy provided.
6 PDPM Overview PDPM is composed of five case mix adjusted payment components and one non-case mix component: q Physical Therapy (PT) q Occupational Therapy (OT) q Speech Language Pathology (SLP) q Nursing q Non-Therapy Ancillaries Services (NTA) q Non-Case Mix Component
7 PDPM Overview All residents will be classified into PT, OT, and SLP categories regardless of whether they are on therapy case load.
8 PT and OT Components Ø PT and OT Case Mix are calculated in the same manner, but paid separately based on separate case-mix indices. Ø Drivers of PT and OT component q Primary reason for skilled stay Utilizes diagnosis codes to classify residents into on of four PT and OT clinical categories q Function Score
9 PT and OT Components Selecting of the primary reason for skilled stay: q Determine resident s primary diagnosis This code, or codes, must be entered into MDS Item I8000. q Utilizing the primary diagnosis identify one of the four clinical categories. Major joint replacement or spinal surgery Other orthopedic Non-orthopedic surgery Medical Management
10 PT and OT Components Selecting of the primary reason for skilled stay: q Some codes may map to more than one clinical category q Further delineation may be made into a surgical category based on specific procedures that occurred during inpatient hospitalization The ICD-10-PCS (procedure code), if utilized to map the resident into a surgical clinical category, must be recorded on the second line of item I8000.
11 PT and OT Components Major Joint Replacement or Spinal Surgery ICD-10-CM Code Description M970- Periprosthetic fracture around internal prosthetic hip joint M971- Periprosthetic fracture around internal prosthetic knee joint M973- Periprosthetic fracture around internal prosthetic shoulder joint S120- Unspecified displaced (or nondisplaced) fracture of first cervical vertebra S Stable burst fracture of unspecified thoracic vertebra S Stable burst fracture of unspecified lumbar vertebra T Broken internal right hip prosthesis T Broken internal left hip prosthesis T Broken internal right knee prosthesis T Broken internal left knee prosthesis Z471 Aftercare following joint replacement surgery
12 PT and OT Components PT and OT Clinical Category Major Joint Replacement or Spinal Surgery Primary Diagnosis Clinical Category Major Joint Replacement Spinal Surgery Other Orthopedic Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Non-Surgical Orthopedic/Musculoskeletal
13 PT and OT Clinical Categories PT and OT Clinical Category Non-Orthopedic Surgery and Acute Neurologic Primary Diagnosis Clinical Category Non-Orthopedic Surgery Acute Neurologic Medical Management Acute Infections Cardiovascular and Coagulations Pulmonary Cancer Medical Management
14 16 PT and OT Case-Mix Groups Clinical Category Function Score PT Case Mix Group CMI Major Joint Replacement or Spinal Surgery 0-5 TA 1.53 Major Joint Replacement or Spinal Surgery 6-9 TB 1.69 Major Joint Replacement or Spinal Surgery TC 1.88 Major Joint Replacement or Spinal Surgery 24 TD 1.92 Other Orthopedic 0-5 TE 1.42 Other Orthopedic 6-9 TF 1.61 Other Orthopedic TG 1.67 Other Orthopedic 24 TH 1.16 Medical Management 0-5 TI 1.13 Medical Management 6-9 TJ 1.42 Medical Management TK 1.52 Medical Management 24 TL 1.09 Non-Orthopedic Surgery and Acute Neurologic 0-5 TM 1.27 Non-Orthopedic Surgery and Acute Neurologic 6-9 TN 1.48 Non-Orthopedic Surgery and Acute Neurologic TO 1.55 Non-Orthopedic Surgery and Acute Neurologic 24 TP 1.08
15 SLP Component Ø ST Case Mix utilizes diagnosis codes to classify residents into neurologic or non-neurologic clinical category q It also utilizes diagnosis coding to capture SLP related comorbidities. Oral Cancers Speech Language Deficits
16 SLP Component Ø Five Characteristics that will impact the SLP Component q Acute Neurologic or Non-Neurologic q SLP-Related Comorbidity q Cognitive Impairment q Mechanically Altered Diet q Swallowing Disorder
17 SLP Component The following comorbidities will be pulled from Section I Active Conditions of the MDS Ø Item I4300. Aphasia Ø Item I4500. CVA, TIA, Stroke Ø Item I4900. Hemiplegia or Hemiparesis Ø Item I5500. Traumatic Brain Injury
18 SLP Component The following comorbidities will be pulled from Section I Active Conditions of the MDS Ø Item I8000. q Laryngeal Cancer q Apraxia q Dysphagia q ALS q Oral Cancers q Speech and Language Deficits
19 SLP Component Condition ICD-10-CM Code Description Speech and Language Deficits I Other speech and language deficits following unspecified cerebrovascular disease Speech and Language Deficits I Aphasia following unspecified cerebrovascular disease Speech and Language Deficits I Dysphasia following unspecified cerebrovascular disease Speech and Language Deficits I Dysarthria following unspecified cerebrovascular disease Speech and Language Deficits I Fluency disorder following unspecified cerebrovascular disease Speech and Language Deficits I Other speech and language deficits following unspecified cerebrovascular disease
20 SLP Component Additional factors utilized to adjust case mix index calculation Ø Mechanically Altered Diet q Determined by K0510C2 Ø Swallowing Disorder q Determined by K0100 Ø Cognitive Impairment q Determined by C0500 or C1000
21 12 SLP Case-Mix Groups Presence of Acute Neurologic Condition, SLP-Related Comorbidity, or Cognitive Impairment Mechanically Altered Diet or Swallowing Disorder SLP Case Mix Group CMI 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
22 Nursing Component Ø Utilizes modified version of the RUG-IV Nursing Categories q Reduced to 25 PDPM RUGS from the original 43 q Diagnosis codes are used to further classify residents into one of the 25 PDPM RUG groups. Ø Nursing Function Score based on Section GG
23 Nursing Component Ø Further division is based on the presence of the following conditions or services: q Tracheostomy and Ventilator/Respirator q Infection Isolation q Depression q Restorative Nursing Services
24 Nursing Component Ø RUGs are grouped into six categories q Extensive Services q Special Care High q Special Care Low q Clinically Complex q Behavioral Cognitive Symptoms q Reduced Physical Function Ø Three categories utilize diagnosis and coding from section I of the MDS.
25 Nursing Component Ø Special Care High Ø Diagnosis Coding in from Section I q Septicemia (I2100) q Diabetes (I2900) with both of the following (N0350A) Insulin injections all 7 days (N0350B) Insulin order changes on 2 or more days
26 Nursing Component Ø Special Care High Ø Diagnosis Coding in from Section I q Quadriplegia (I5100) with Nursing Function Score greater than or equal to eleven (11) q COPD (I6200) and J1100C SOB when lying flat
27 Nursing Component Ø Special Care High q Fever (J1550A) and one of the following: q Pneumonia (I2000) q Vomiting (J1550B) q Weight Loss (K0300, 1 or 2) q Feeding Tube (K0510B1 or K0510B2)
28 Nursing Component Ø Special Care Low q Diagnosis Coding q Cerebral palsy (I4400) and Nursing Function Score of 11 or greater q Multiple Sclerosis (I5200) and Nursing Function Score of 11 or greater q Parkinson's (I5300) and Nursing Function Score of 11 or greater q Respiratory Failure (I6300) and Oxygen therapy while a resident (0100C2)
29 Nursing Component Ø Clinically Complex q Diagnosis Coding q Pneumonia (I2000) and Nursing Function Score of 11 or greater
30 Nursing Case Mix Groups
31 Non-Therapy Ancillary (NTA) Component Ø Utilizes 50 diagnosis codes and extensive services to identify additional comorbidities Ø Must be coded on the UB04 or MDS Ø Utilizes a points scale from 1 to 8 to calculate comorbidity score
32 NTA Component Ø The following conditions will be pulled from Section I Active Conditions of the MDS. Ø Multiple Sclerosis (I5200) Ø Asthma, COPD, Chronic Lung Disease (I6200) Ø Wound Infections (I2500) Ø Diabetes Mellitus (DM) (I2900) Ø Multi-Drug Resistant Organism (MDRO) (I1700) Ø Malnutrition (I5600)
33 NTA Component Ø The following conditions will be pulled from Section I Active Conditions of the MDS. Ø I8000 Additional Diagnoses q Lung Transplant Status q Major Organ Transplant Status, Except Lung q Opportunistic Infections q Bone, Joint, Muscle Infections/Necrosis, Except Aseptic Necrosis of Bone q Chronic Myeloid Leukemia q Endocarditis
34 NTA Component Ø The following conditions will be pulled from Section I Active Conditions of the MDS. Ø I8000 Additional Diagnoses q Immune Disorders q End-Stage Liver Disease q Narcolepsy and Cataplexy q Cystic Fibrosis q Specified Hereditary Metabolic and Immune Disorders q Morbid Obesity
35 NTA Component Ø The following conditions will be pulled from Section I Active Conditions of the MDS. Ø I8000 Additional Diagnoses q Psoriatic Arthropathy and Systemic Sclerosis q Chronic Pancreatitis q Proliferative Diabetic Retinopathy and Vitreous Hemorrhage q Complications of Specified Implanted Device or Graft q Inflammatory Bowel Disease
36 NTA Component Ø The following conditions will be pulled from Section I Active Conditions of the MDS. Ø I8000 Additional Diagnoses q Aseptic Necrosis of Bone q Cardio-Respiratory Failure and Shock q Myelodysplastic Syndromes and Myelofibrosis q Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Hemorrhage q Severe Skin Burn or Condition
37 NTA Component Ø The following conditions will be pulled from Section I Active Conditions of the MDS. Ø I8000 Additional Diagnoses q Diabetic Retinopathy, Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage q Intractable Epilepsy q Disorders of Immunity q Cirrhosis of Liver q Respiratory Arrest q Pulmonary Fibrosis & Other Lung Disorders
38 NTA Component Comorbidity Description ICD-10-CM Code ICD-10-CM Code Description Endocarditis A0102 Typhoid fever with heart involvement Endocarditis A1884 Tuberculosis of heart Endocarditis A3282 Listerial endocarditis Endocarditis A3951 Meningococcal endocarditis Endocarditis A5203 Syphilitic endocarditis Endocarditis A78 Q fever Endocarditis B3321 Viral endocarditis Endocarditis B376 Candidal endocarditis Endocarditis I330 Acute and subacute infective endocarditis Endocarditis I339 Acute and subacute endocarditis, unspecified Endocarditis I38 Endocarditis, valve unspecified Endocarditis I39 Endocarditis and heart valve disorders in diseases classified elsewhere Endocarditis M3211 Endocarditis in systemic lupus erythematosus
39 NTA Component Ø HIV/AIDS add-on Ø Applied based on the presence of ICD-10-CM code B20 on the SNF claim. Ø Due to the significant increase in nursing cost to care for HIV/AIDS patients, the facility will get an 18% increase in NTA category.
40 NTA Case Mix Groups NTA Comorbidity Score NTA Case Mix Group CMI 12+ NA NB NC ND NE NF 0.72
41 Coding Pitfalls and Tips
42 Principal Diagnosis Ø 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. Ø This definition has been expanded to include ALL non-outpatient settings including SNFs / LTC facilities.
43 Principal Diagnosis 43 Ø When a patient is treated for an acute condition in the hospital and transferred to a SNF for rehab q The acute condition, if still present is coded as the first listed/principal diagnosis. q The aftercare is coded as the first listed/principal diagnosis, if the acute condition is no longer present.
44 Principal Diagnosis 44 Ø When a patient transitions to long term care or returns from hospital stay for continued long term care q The chronic condition, that requires continued stay for long term care is the first listed/principal diagnosis. q The acute condition or aftercare is sequenced as the first additional/secondary diagnosis.
45 Additional Diagnoses 45 Ø Secondary/Additional Diagnoses conditions that coexist at the time of admission, that develop subsequently during the resident s stay or that affect the treatment the resident receives or the resident s length of stay. q Diagnosis that support both the Principle Dx. This is where you would include the therapy treatment diagnosis codes as they support the Admit Dx
46 Additional Diagnoses 46 Ø Medicare Claims Processing Manual, Chapter Six, page 33, indicates the Principal Diagnosis and up to eight additional diagnosis codes are included in the claims review process. Ø This makes it imperative to get the most pertinent diagnoses requiring skilled services in the top 8 boxes of this section.
47 Common Coding Errors 47 Ø Incorrect selection of principal diagnosis Ø Coding and Sequencing of Hypertension (HTN) with Chronic kidney disease (CKD) Ø Coding External Causes (V00-Y99) Ø Coding UTI without meeting all of the criteria per the Resident Assessment Instrument (RAI) Manual
48 Common Coding Errors 48 Ø Coding Aftercare codes (Z codes) with injury or fracture codes with a 7 th character that identifies the encounter type Ø Incorrect 7 th character selection for injury and fracture codes to identify the encounter type Ø Coding conditions to a lower or higher level of specificity than provider documentation supports
49 Common Coding Errors 49 Ø Coding acute condition, when conditions is resolved and skilled care is focused on the sequela or aftercare Ø Coding symptoms with presence of a definitive diagnosis
50 Risks of Inaccurate Coding
51 Risks of Incorrect Coding 51 Ø Inaccurate health record Ø Incomplete or inaccurate data on the MDS Ø Incomplete or inaccurate data on the UB04
52 Inaccurate Health Record 52 Ø Risk Management Ø Diagnosis of osteoporosis in a resident that obtains a fracture after rolling out of the bed in lowest position onto fall mats. q Coding guidelines indicate that the fracture may be coded as a pathologic fracture. Ø Quality Care Ø Resident specific care based in part on their specific diagnoses and other care needs.
53 Incomplete/Inaccurate MDS 53 Ø Care Planning Ø Diagnoses aid in identification of problems and determination of interventions Ø Quality Measures Ø Percentage of Short Stay Residents with Pressure Ulcers that are New or Worsening q Includes Covariates related to diabetes or peripheral vascular disease coded in Section I
54 Incomplete/Inaccurate UB 54 Ø Claims Denials Ø Remittance advice informs of invalid diagnosis, but does not specify which code or sequence Ø Quality Measures Ø SNF Readmission Measure (SNFRM) q Exclusions include hospitalized for primary diagnosis related to medical (non-surgical) treatment of cancer
55 Planning
56 What s Next 56 Ø Complete routine coding and MDS audits Ø Ensure staff have current ICD-10-CM code books Ø Updated every October 1 st Ø Provide staff with basic ICD-10-CM training Ø Provide staff with PDPM training
57 What s Next 57 Ø Ensure that all disciplines are utilizing the same primary diagnosis Ø Review diagnosis coding during Triple Check (Pre-Bill) meeting Ø Review code updates effective October 1 st and revise codes for current residents, as needed
58 Q & A 58 Questions???
59 Thank you for your participation To learn more about this topic please contact Heather Py, RHIT, CCS, CHPS, RAC-CT, Director of Health Information Management at You may also contact Robin A. Bleier, President with regard to this or other services at or call us at RB Health Partners, Inc.
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