Q: Our facility is having trouble selecting the primary diagnosis code under I0020 and I0200B. How can we establish a process to simplify this task?

A: Section I of the MDS captures a patient’s active diagnosis, which must be documented by the physician within the last 60 days and directly relate to the patient’s status during the 7-day look-back period. I0020 and I0020B are typically completed only on the 5-Day or interim payment assessment (IPA), but may also be required on OBRA assessments if the state opted to collect PDPM billing codes. I0020 indicates the medical condition category that best describes the primary reason for admission, then I0020B reports the ICD-10-CM code for that condition. 

The primary diagnosis is the main reason why the patient requires skilled care in the nursing home. It is the one used to drive the care plan during the stay. The skilled nursing facility Medicare interdisciplinary team should meet to discuss the resident’s diagnoses, information from the acute-care hospital, and physician documentation to determine which diagnosis best explains the reason for medically-necessary skilled services in the SNF. The SNF team may need to query the physician for a more specific diagnosis. 

Some patients may have several diagnoses that could be primary. If that is the case, the team must determine which one will be considered primary and document its process and rationale. Consider a long-term care resident originally admitted to the SNF with a diagnosis of Parkinson’s disease who later fell and fractured his hip. When readmitted to the SNF for rehabilitation, the primary reason for his skilled stay becomes aftercare of the fracture, not Parkinson’s disease. 

Establishing a team process for review and selection of the primary diagnosis will help to align care plans across clinical and therapy teams and ensure that I0020 is coded correctly.