The long-awaited final rule for FY 2022 provided updates in payment rates, wage index, value-based purchasing, quality reporting and a pause to the anticipated parity adjustment.
Of equal interest, we see some positive updates to ICD-10 mappings, which are aimed at more effectively reflecting clinical accuracy for the patients we serve daily.
Therapists take note: Understanding these changes will impact coding accuracy in the new fiscal year.
As a reminder, PDPM utilizes International Classification of Diseases, Version 10 (ICD-10) codes in several ways, including assigning patients to clinical categories used for categorization under several PDPM components, specifically the PT, OT, SLP and NTA components.
The ICD-10 code mappings and lists used under PDPM are available on the PDPM Website. In response to stakeholder feedback and to improve consistency between the ICD-10 code mappings and current ICD-10 coding guidelines, the Centers for Medicare & Medicaid Services is proposing several changes to the PDPM ICD-10 code mappings affecting the areas of sickle-cell disease, esophageal conditions, multisystem inflammatory syndrome, neonatal cerebral infarction, vaping-related disorder and anoxic brain damage.
What should these changes mean to you? Well, most importantly that your voice matters.
These changes are occurring secondary to feedback from the industry and review of specific condition impacts on care needs in skilled nursing facility settings.
Let’s review changes and justifications in more detail together.
Sickle Cell Disease – changes from medical management to return to provider
On October 1, 2020, two ICD-10 codes representing types of sickle-cell disease — D57.42 “Sickle-cell thalassemia beta zero without crisis” and D57.44 “Sickle-cell thalassemia beta plus without crisis” — took effect and were clinically mapped to the category of “Medical Management.”
However, there are more specific codes to indicate why a patient with sickle-cell disease would require SNF care, and if the patient is not in crisis, this most likely indicates that SNF care is not required. For this reason, CMS will change the assignment of D57.42 and D57.44 to “Return to Provider.”
Esophageal Conditions – changes from return to provider to medical management
On October 1, 2020, three new ICD-10 codes representing types of esophageal conditions took effect and were clinically mapped to “Return to Provider:” K20.81, “Other esophagitis with bleeding,” K20.91, “Esophagitis, unspecified with bleeding” and K21.01, “Gastro-esophageal reflux disease with esophagitis, with bleeding.”
Upon review of these codes, CMS recognized that these codes represent these esophageal conditions with more specificity than originally considered because of the bleeding that is part of the conditions and that they would more likely be found in SNF patients.
Therefore, they will change the assignment of K20.81, K20.91 and K21.01 to “Medical Management” in order to promote more accurate clinical category assignment.
Multisystem Inflammatory Syndrome – changes from non-surgical orthopedic/musculoskeletal to medical management
In December 2020, the CDC announced several additions to the ICD-10 Classification related to COVID-19 that became effective on Jan. 1, 2021. One such code, M35.81 “Multisystem inflammatory syndrome,” was assigned to “Non-Surgical Orthopedic/Musculoskeletal.”
However, Multisystem inflammatory syndrome can involve more than the musculoskeletal system. It can also involve the gastrointestinal tract, heart, central nervous system and kidneys.
For this reason, CMS will change the assignment of M35.81 to “Medical Management” in order to promote more accurate clinical category assignment.
Neonatal Cerebral Infarction – changes from return to provider to acute neurologic
On Oct. 1, 2020, three new ICD-10 codes representing types of neonatal cerebral infarction were classified as “Return to Provider.”
These codes were P91.821, “Neonatal cerebral infarction, right side of brain,” P91.822, “Neonatal cerebral infarction, left side of brain” and P91.823, “Neonatal cerebral infarction, bilateral.”
While a neonate is unlikely to be a Medicare beneficiary, this diagnosis could continue to be used later in life hence placing those with this condition in the acute neurologic category.
Therefore, CMS will change the assignment of P91.821, P91.822 and P91.823 to “Acute Neurologic” in order to promote more accurate clinical category assignment.
Vaping-Related Disorder – changes from return to provider to pulmonary
On April 1, 2020, U07.0, “Vaping-related disorder,” took effect and was classified as a “Return to Provider” code because, at the time, “Vaping-related disorder” was not considered a code that would be a primary diagnosis during a SNF stay.
However, CMS states that upon further review, many patients who exhibit this diagnosis require steroids, empiric antibiotics, and oxygen for care, which could carry over to the post-acute setting.
For this reason, they will change the assignment of U07.0 to “Pulmonary” classification in order to promote more accurate clinical category assignment.
Anoxic Brain Damage -changes from return to provider to acute neurologic
The ICD-10 code, G93.1 was initially clinically mapped to “Return to provider” because “Anoxic brain damage, not elsewhere classified” was non-specific and did not fully describe a patient’s deficits and may not have been an acute condition.
However, upon further review, our clinicians determined that although this may not be an acute condition, “Anoxic brain damage, not elsewhere classified” would still likely result in a need for SNF care and is similar to conditions such as “Compression of the brain,” “Cerebral edema” and “encephalopathy,” which are mapped into the “Acute Neurologic” category.
Therefore, we will change the assignment of G93.1 “Anoxic brain damage, not elsewhere classified” to “Acute Neurologic.”
In closing, changes are coming. Take note!
These are some positive steps to ensuring care and reimbursement align with patient needs, evidence-based practice and the unique level of skilled care you provide daily.
Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the 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).
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.