Caryn Adams

Why is ICD-10 a hot topic again?

ICD-10 coding should be high-priority on everyone’s list this year as we await the rollout of the Patient-Driven Payment Model. I do not think it can be stressed enough that diagnoses are driving reimbursement. 

ICD-10 is important in that it reports data about our residents and that data is used for trending and to identify cost drivers. Diagnoses also are used in value-based purchasing and the quality reporting program to identify exclusions, risk adjusters and planned readmissions.

In PDPM, each diagnosis maps to a clinical category, which assigns a case-mix group, which translates to a case-mix index, which translates to reimbursement.

Remember that there are five different components to reflect the individual needs or characteristics of resident care. Payment is based on the case-mix index for each component — the diagnosis affects the rate for each component. Comorbidities also impact the non-therapy ancillary rate. It is important for the facility to be ahead of this.  

Identify the top used diagnoses in your facility. Map them to the clinical categories. If they are not falling where you think they should, you need to
identify why. Review the codes for specificity. Coding guidelines dictate to code to the highest specificity. 

If an unspecified diagnosis is listed, the coder needs to query the provider for clarification. Make sure that the correct seventh character is being used for injuries and poisonings. Also, note when aftercare codes (Z codes) are used and are not used. 

All diagnoses that are coded must be supported by provider documentation. If there is a question, the provider must be queried.

Please send your payment-related questions to Caryn Adams at [email protected].