Our facility has a list of commonly used diagnoses for newly admitted residents, but we are being told to avoid using such lists. Can you explain why this should be avoided?

Confusion abounds surrounding coding diagnoses on the MDS and billing claims. It is easy to get caught up in using diagnoses that map to case-mix classifications since they impact reimbursement under PDPM. But diagnoses affect more than just reimbursement. 

They also are used for care planning and telling a story on the claim. To appropriately code every resident’s diagnoses, you must review what is documented in their medical record and look up the resident’s diagnoses in the ICD-10-CM coding manual. Using this manual is imperative to validate that the proper code is entered and that all coding notes, exclusions, 7th digits, and more are correct prior to entry. Let’s look at examples why: 

Two residents admit, both with right hip replacement surgery prior to admission. On your list of diagnoses, you see Z47.1 listed as aftercare following joint replacement surgery, so you assign both residents this code. Your list doesn’t indicate that you also must code the joint impacted, so you use only this single code. 

After reviewing the medical record, you see that Mr. Smith had a hip replacement due to osteoarthritis, while Mrs. Jones had a hip replacement because of a fracture. Their ICD-10 codes are not the same since they had hip replacement surgery for very different reasons. 

Using an incorrect code could create problems with claim review or lead to inaccurate reimbursement. The only way to get the correct ICD-10 code (and any additional inclusions, exclusions, and 7th digits) for the MDS and claim is to look up the code in the ICD-10 coding manual.