Until the early 1500s, virtually everyone held the truth that the Earth was the center of the universe. Then the Polish scientist Nicolaus Copernicus proposed that the planets actually revolve around the sun, a fact that we live by today.
In the past, our skilled nursing world has revolved around a sun of its own, known as resource utilization groups (particularly the lucrative high-therapy ones). Now, however, according to the details of the new Medicare fee-for-service reimbursement model known as the Patient Driven Payment Model (PDPM), it seems that we’ll soon be revolving around a different sun altogether: ICD-10 codes.
For SNF providers, this means that the old ways of doing business, or at least documenting resident assessments on the MDS, won’t work under the new model. One of the most significant changes is the promotion of diagnoses to be key drivers for reimbursement under PDPM. Beginning October 1, 2019, diagnoses (specifically ICD-10 codes) will be used to place the resident into one of 10 PDPM clinical categories which will determine the payment components for physical therapy (PT)/occupational therapy (OT), speech, and nursing skilled services, as well as non-therapy ancillary (NTA) costs.
While this new model will deliver reimbursement that is much more specific to the clinical needs of the resident, it also challenges SNFs to up their ICD-10 coding game.
Do you know how diagnoses are currently being captured in your center’s MDS data? Don’t be embarrassed if you don’t; to be frank, up until now the coding of diagnoses on the MDS has not been terribly high on the list of priorities. Diagnoses are vital for care planning, but the majority of them don’t impact Quality Measures or RUG-based reimbursement. There’s the rub: Under RUG-IV, a resident with diabetic retinopathy (for example) who is on skilled PT and OT would not be classified by that diagnosis, but only by the amount of therapy provided, so the primary diagnosis on the claim would be related to the reason for skilled therapy. According to the coding definition on the MDS, diabetic retinopathy is covered by simply checking item I2900, Diabetes Mellitus; no specific ICD-10 code is required. While under RUG-IV the reimbursement for this resident wouldn’t be affected by the diagnosis, under PDPM, this MDS coding would result in under-reimbursement (more on this below).
Think about how your facility currently determines the primary diagnosis to enter on the UB-04 for a resident receiving skilled services. Oftentimes this process is driven by the treatment diagnosis codes found in the therapy evaluation and plan of care. While this would seem to be the most effective process for PDPM, many ICD-10 codes which have traditionally been used for therapy under RUG-IV, will trigger a “return to provider” status if they are used as a primary diagnosis under the new payment model. Some examples of these treatment diagnoses include M62.81, Muscle Weakness (generalized); R26.9, Unspecified Abnormalities of Gait and Mobility; or R13.10, Dysphagia, Unspecified.
To find out how frequently these treatment diagnoses listed above are being coded on the MDS, we analyzed 582,007 5-day MDSs for calendar year 2017. The most frequently used code of the three was M62.81, which was coded in the first position in MDS item I8000A on 57,314 MDSs (9.85%). While that may not seem like a significant percentage, under PDPM it would result in almost 10% of your Medicare claims being rejected. And remember, this was only one example of the “return to provider codes” that would be rejected.
How should your facility address problems with diagnosis coding? This is a job for your interdisciplinary team to tackle together:
- Bring together all of your colleagues who contribute to the diagnosis documentation, including the physician or NP, PT/OT/SLP, and other specialty care professionals such as wound specialists or dieticians; also include your medical records department to ensure that their policies and processes are up to speed with the more detailed requirements.
- Download the CMS PDPM ICD-10 Crosswalk and line it up against a list of your most commonly used codes.
- First, look for the codes that are classified “Return to Provider” and have the responsible discipline run through the exercise of finding a more specific primary diagnosis.
- Also, remember that aftercare codes can still be the primary diagnosis if that is the primary reason for SNF admission, e.g. Z47.89, Encounter for Other Orthopedic Aftercare. This diagnosis would come from the documentation of the discipline involved, which may be therapy for PT/OT or nursing if the aftercare is primarily nursing treatments.
Making sure that a complete picture of the resident’s medical diagnoses is coded on the MDS will also ensure appropriate scoring of NTAs. Going back to our resident with diabetic retinopathy, we would code I2900 for the Diabetes, as well as the ICD-10 code for Diabetic Retinopathy in I8000 (E11.3xxx depending on the specific diagnosis) to add another point to the NTA score.
Once you have the proper ICD-10 codes for your resident, where do you put them on the MDS to ensure that they are capturing the right clinical categories? Think primary and secondary reasons for the SNF stay. In RUG-IV, the order of coding the diagnoses in MDS section I8000 is not formally defined, but PDPM requires a specific order. The primary medical diagnosis goes in the top row (I8000A). If the resident had an inpatient procedure (such as orthopedic surgery), then the ICD-10-PCS for that procedure would be coded in the second row (I8000B). This second code determines the PT, OT and SLP clinical categories in the PDPM classification. The rest of the I8000 rows are in no particular order, but you would use them to capture other comorbidities for the NTA scoring (such as diabetic retinopathy).
Preparing for PDPM seems like a monumental task (because it is!) but unlike Copernicus, you shouldn’t have the fear of being branded a heretic for trying to conquer these new ideas. (In fact, Copernicus waited until he was on his deathbed before finally publishing his book in 1543.) Please don’t wait that long to start your transition plans. Instead, begin by taking these steps now:
- Start by looking for those diagnoses that you use the most, and work from there to practice capturing the most specific ICD-10 codes possible.
- Make sure diagnoses that often get buried in the checklist in Section I are brought out and coded in I8000 to capture the NTA.
- Work with your physicians and physician extenders to make sure that they are documenting the specific diagnoses to get the right ICD-10 codes.
- And most importantly, communicate with your interdisciplinary team and ask: Why is the resident here? If you can answer that question with the right diagnosis, you can be confident of PDPM success.
Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.