REIMBURSEMENT AND ICD-10 CODING December 2018 - RB Health Partners, Inc.
Objectives
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
Diagnoses and PDPM
Patient-Driven Payment Model (PDPM) Overview PDPM uses clinical conditions to determine the resident s payment category, rather than the amount of therapy provided.
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
PDPM Overview All residents will be classified into PT, OT, and SLP categories regardless of whether they are on therapy case load.
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
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
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.
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 S22001- Stable burst fracture of unspecified thoracic vertebra S32001- Stable burst fracture of unspecified lumbar vertebra T84010- Broken internal right hip prosthesis T84011- Broken internal left hip prosthesis T84012- Broken internal right knee prosthesis T84013- Broken internal left knee prosthesis Z471 Aftercare following joint replacement surgery
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
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
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 10-23 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 10-23 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 10-23 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 10-23 TO 1.55 Non-Orthopedic Surgery and Acute Neurologic 24 TP 1.08
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
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
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
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
SLP Component Condition ICD-10-CM Code Description 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 Speech and Language Deficits I69.921 Dysphasia following unspecified cerebrovascular disease Speech and Language Deficits I69.922 Dysarthria following unspecified cerebrovascular disease Speech and Language Deficits I69.923 Fluency disorder following unspecified cerebrovascular disease Speech and Language Deficits I69.928 Other speech and language deficits following unspecified cerebrovascular disease
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
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
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
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
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.
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
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
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)
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)
Nursing Component Ø Clinically Complex q Diagnosis Coding q Pneumonia (I2000) and Nursing Function Score of 11 or greater
Nursing Case Mix Groups
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
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)
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
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
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
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
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
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
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.
NTA Case Mix Groups NTA Comorbidity Score 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
Coding Pitfalls and Tips
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.
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.
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.
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
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.
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
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
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
Risks of Inaccurate Coding
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
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.
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
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
Planning
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
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
Q & A 58 Questions???
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 heather@rbhealthpartners.com. You may also contact Robin A. Bleier, President with regard to this or other services at robin@rbhealthpartners.com or call us at 727.786.3032. 2018 RB Health Partners, Inc.