Renee Kinder

If the goal of the Patient Driven Payment Model was to encourage interprofessional collaboration, coding and increase integration across care teams, well, I would say it is working! 

The ability to digest all the coding MDS conundrums, however, has resulted in some creative questions related to the PDPM areas associated with swallow and diet.

What has ensued is an alphabet soup of sorts, merging the elements of Section K: Swallowing and Nutritional Status, Section GG: Self Care Eating, and Section I: Active Diagnoses

Some of my favorites?

Q: Why do only the “I” series codes “count” to dysphagia?

A: When I see this question, I begin with an explanation of the speech pathology (SLP) case mix group and how the elements are obtained. To begin, there are 12 total SLP case mix groups determined based on the following: presence of acute neuro condition, SLP related co-morbidity, or cognitive impairment & mechanically altered diet or swallowing disorder.

The dysphagia codes which are attributed to the comorbidity filter from Section I of the MDS are based, as many areas within PDPM, on historical claims data. For this reason, the “I” series cerebrovascular codes are the ICD-10 codes noted to trend to the specificity of SLP services. 

The codes included in co-morbidities for the SLP case mix are as follows:

DysphagiaI69091Dysphagia following nontraumatic subarachnoid hemorrhage
DysphagiaI69191Dysphagia following nontraumatic intracerebral hemorrhage
DysphagiaI69291Dysphagia following other nontraumatic intracranial hemorrhage
DysphagiaI69991Dysphagia following unspecified cerebrovascular disease

Q: Can I change an “R” series to be an “I” series?

A: Use of the “I” series codes must also adhere to the definition of “Active Diagnosis” and is not interchangeable when the “R” series codes are most appropriate for the patient based on clinical presentation and medical history. 

Active diagnoses are defined in the RAI Manual as physician-documented diagnoses in the last 60 days that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. 

Additionally, coding principles for ICD-10 direct us to use an “R” series, which are the dysphagia phase specific codes, to identify impaired phase when using an “I”. 

R-series swallow codes used to obtain phase specificity include:

R13.11 Oral Phase

R13.12 Oropharyngeal Phase

R13.13 Pharyngeal Phase

R13.14 Pharyngoesophageal Phase

In short — and “I” code should be followed by an “R” code — they should not stand alone.

Furthermore, the “R” series codes help to support the clinical elements seen in K0100 A-D therefore “not using” or eliminating them from the medical record would create a void when we are all aware PDPM is intended to encourage a greater level of congruence across care teams’ documentation.

K0100 Areas Defined:

  • K0100A, loss of liquids/solids from mouth when eating or drinking. When the resident has food or liquid in his or her mouth, the food or liquid dribbles down chin or falls out of the mouth. 
  • K0100B, holding food in mouth/cheeks or residual food in mouth after meals. Holding food in mouth or cheeks for prolonged periods of time (sometimes labeled pocketing) or food left in mouth because resident failed to empty mouth completely. 
  • K0100C, coughing or choking during meals or when swallowing medications. The resident may cough or gag, turn red, have more labored breathing, or have difficulty speaking when eating, drinking, or taking medications. The resident may frequently complain of food or medications “going down the wrong way.” 
  • K0100D, complaints of difficulty or pain with swallowing. Resident may refuse food because it is painful or difficult to swallow. 

In short: Don’t swap “R” for “I” or eliminate the use of “R” codes.

Q: But Renee, they are return to provider codes? If speech has them on their plan of care, I am worried the entire claim will “kick out.”

A: But remember that the RTP is associated with I0020B. Therefore, simply be mindful in what codes best define the acute care stay and ensure they are used according in I0200B. 

Per the RAI, I0020B is used to indicate the resident’s primary medical condition category that best describes the primary reason for the Medicare Part A stay. Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes and other resources as available. 

Q: If a CNA cuts food for an individual on a regular diet for the Self-Care Eating GG0130A with tray set-up, is this considered “modified diet” to meet criteria in K0150c2?

A: To begin, we need to review the coding language within the RAI manual and understand that these are two distinct areas of the MDS here with defined criteria for coding. 

GG0130A is defined as the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. 

The question above in actuality is looking at Eating criteria from Section G0110 and per the RAI is an example of ADL Set-Up Support, Eating—cutting meat and opening containers at meals; giving one food item at a time.

Now to Section K0150c2. This section defines a mechanically altered diet as follows:

 A diet specifically prepared to alter the texture or consistency of food to facilitate oral intake. Examples include soft solids, puréed foods, ground meat, and thickened liquids. A mechanically altered diet should not automatically be considered a therapeutic diet.

In closing, I hope I have given you some things to digest!

As we continue to chew on coding definitions and savor the benefits of team collaboration, don’t get choked! 

Remember to keep your RAI close, stay tuned to Q and A updates provided on, and relish the opportunity to get coding right together. 

It will, after all, make these areas much easier to swallow. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Encore Rehabilitation and 2019 APEX Award of Excellence winner in Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).