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ICD-10-CM AND
THE PDPMMary Ann P. Leonard, RHIA, RAC-CT
Health Information Professionals
ICD-10-CM AND THE PDPM
OBJECTIVES
■ To understand how the ICD-10-CM codes are utilized by the
new payment system
■ To understand how the Clinical Category Mapping is utilized
■ To understand in which ‘buckets’ of the PDPM the diagnostic
code is being used
■ To provide recommendations related to the best utilization
of the ICD-10-CM codes
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ICD-10-CM AND THE PDPM
ICD-10-CM SOURCE
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ICD-10-CM AND THE PDPM
Where does the International Classification of Disease, Clinical
Modification (ICD-10-CM) come from?
■ Developed through the World Health Organization
■ Adopted by countries around the globe
■ Adapted for the needs of the specific country
■ Utilized to gather information/statistics on diseases
■ Beta testing for ICD-11-CM has been completed
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ICD-10-CM AND THE PDPM
Sources for criteria for assigning the ICD-10-CM codes
■ Coding Guidelines published by CDC, DHHS/CMS
■ Coding Clinic published by the American Hospital
Association
– Managed by the Cooperating Parties – American
Hospital Association, American Health Information
Association, National Center for Health Statistics,
Centers for Medicare/Medicaid Services
– Question and answer format, questions/situations
submitted by multiple sources
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ICD-10-CM AND THE PDPM
What was the impact of ICD-10-CM in the past?
■ ICD-10-CM codes were not utilized under RUGs as a direct
impact on reimbursement
■ Diagnoses which impacted RUGs were primarily check-offs
in section I, e.g. hemiplegia, Diabetes Mellitus or
incorporated in other section of the MDS e.g. Section O for
trach/vent care
■ Under PDPM there is a direct relationship between the code
assignment and payment categories
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ICD-10-CM AND THE PDPM
Factors which impact ICD-10-CM code assignment
■ Information provided from acute care – ranges from nothing
to volumes of paper/information (some provide EHR portals)
■ Can only use diagnoses documented by a provider
(physician, nurse practitioner or physician assistant)
■ Lack of specificity from the provider e.g. hip fracture,
pneumonia, stroke, DM, HTN, etc.
■ Lack of clarity re: the principal or primary diagnosis
■ Culture of therapy seen as the driving force for skilled care
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POLICY AND PROCEDURE
Every facility should have a policy/procedure on diagnostic code assignment
Some items to be addressed are, but not limited to,
–Following the Coding Guidelines
–What diagnoses are to be used
–Timeframe for coding
–Documentation sources for the diagnoses
–Querying of the Provider
8
CODING WITH ICD-10-CM AND THE MDS (ACCORDING TO THE PA RAI
COORDINATOR)
Coding diagnoses in Section I is not based on ICD codes.
Alzheimer's, Huntingdon's, and Parkinson’s disease each have a
corresponding item on the MDS, and would be coded if the criteria stated
in the RAI User’s Manual are met.
The basics of coding a diagnosis include:
■ The disease conditions in Section I require a physician documented
diagnosis in the resident's medical record such as in: physician progress
notes, recent history and physical, recent discharge summaries,
medication sheets, doctor’s orders, consults and official diagnostic reports.
■ If a diagnosis/problem list is used, only diagnoses confirmed by the
physician should be entered.
CODING WITH ICD-10-CM AND THE MDS
Coding diagnoses in Section I is not based on ICD codes (cont.)
■ Diagnoses communicated verbally must be documented in the medical record by the
physician to ensure follow-up.
■ Diagnostic information, including past history obtained from family members and close
contacts, must also be documented in the medical record by the physician to ensure
validity and follow-up.
■ Once a diagnosis is identified, it must be determined if the diagnosis is active. Active
diagnoses are diagnoses that have a direct relationship to the resident’s current functional,
cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of
death during the 7-day look-back period.
■ Conditions that have been resolved, do not affect the resident’s current status, or do not
drive the Resident’s plan of care during the 7-day look-back period, are considered inactive
diagnoses, and are not coded on the MDS.
Pennsylvania RAI Coordinator
ICD-10-CM AND THE PDPM
Some coding rules which directly impact SNF code assignment
■ Diagnoses must be documented by the provider within the last 60 days ( of the ARD) and active within the last 7 days (RAI Manual)
■ Infections which were treated in the hospital and treatment is completed before they arrive at the SNF, the infection cannot be coded (e.g. UTI, Pneumonia, Sepsis, etc.)
■ Long term residents who return after a hospital admission must be coded to the reason why they are long term (e.gAlzheimer's, dementia, Parkinson's, MS, CVA with sequela, etc.)
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ICD-10-CM AND THE PDPM
Some coding rules which directly impact SNF code assignment
■ Use of 7th character to identify the episode of care still
applies
– A – initial (acute) episode of care (diagnostic)
– D – subsequent episode of care (treatment)
– S – sequela episode of care (residual from previous
injury or trauma
■ Stroke related codes are I69 not I63, etc.
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ICD-10-CM AND THE PDPM
Some implications with the Clinical Category Mapping
■ Most rehab codes will not be accepted as the primary
diagnosis – “Return to Provider”
■ Lack of specificity in code assignment could generate a
“Return to Provider” response
■ Secondary diagnoses will impact the final payment through
the Non Therapy Ancillaries (NTA) points, e.g. transplant,
morbid obesity, MS, CP, COPD, DM, etc.
■ The ICD-10-CM code must appear in I8000, if not a check-
off, in order to receive the designated point/s
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ICD-10-CM AND THE PDPM
Some diagnostic codes which are “Return to Provider” when primary (under a recent vendor study “Return to Provider” codes were @ 10% of the primary diagnoses)
■ M62.81 Muscle weakness
■ Z87.01 Personal History of pneumonia
■ Z51.81 Encounter for other specified aftercare
■ Z48.89 Encounter for other specified surgical aftercare
■ S82.486D Nondisplaced transverse fracture of shaft of
unspecified fibula, routine healing
■ R62.7 Adult failure to thrive
■ R53.1 Weakness
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ICD-10-CM AND THE PDPM
Some diagnostic codes which are “Return to Provider” when primary
■ R53.2 Functional quadriplegia
■ R53.81 Malaise
■ R54 Age related debility
■ R41.82 Altered mental status
■ R41.81 Age related cognitive decline
■ R29.6 Repeated falls
■ R27.9 Unspecified lack of coordination
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ICD-10-CM AND THE PDPM
Some diagnostic codes which are “Return to Provider” when primary
■ R26.9 Unspecified abnormalities of gait
■ R13.--- Dysphagia (all phases)
■ I69.369 Other paralytic syndrome following cerebral
infarction affecting unspecified side
■ I69.359 Hemiplegia and hemiparesis following cerebral
infarction affecting unspecified side
■ K92.2 Gastrointestinal hemorrhage, unspecified
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ICD-10-CM AND THE PDPM
Some diagnostic codes which are “Medical Management” or
“Acute Neurologic” when primary
■ R26.0 Ataxic gait
■ R26.1 Paralytic gait
■ R26.89 Other abnormalities of gait and mobility
(Nonsurgical orthopedic/Musculoskeltal)
■ R27.0 Ataxia, unspecified
■ R27.8 Other lack of coordination
■ R29.1 Meningismus
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ICD-10-CM AND THE PDPM
Some diagnostic codes which are “Medical Management” or
“Acute Neurologic” when primary
■ R29.818 Other symptoms and signs involving the
nervous system
■ R29.898 Other symptoms and signs involving the
musculoskeletal system
■ R40.3 Persistent vegetative state
■ R41.44 Neurologic neglect syndrome
■ R41.842 Visuospatial deficit
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ICD-10-CM AND THE PDPM
Some diagnostic codes which are “Medical Management” or
“Acute Neurologic” when primary
■ R47.01 Aphasia
■ R47.02 Dysphasia
■ R47.1 Dysarthria and anarthria
■ R47.89 Other speech disturbances
■ R48.2 Apraxia
■ R53.0 Neoplastic (malignant) related fatigue
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ICD-10-CM AND THE PDPM
Five mistakes often made selecting ICD-10-CM codes in the
SNF
■ Using unspecified codes
■ Coding resolved diagnoses
■ Incorrect 7th character
■ Coding from the internet, a cheat sheet or facility software
■ Coding a diagnosis that was not documented by a Provider
SOURCE: Jessie McGill, AANAC newsletter
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ICD-10-CM AND THE PDPM
Other mistakes often made selecting ICD-10-CM codes in the
SNF
■ Using multiple single codes when a one i.e. a “combination
code”, will do (acute on chronic codes) e.g. acute on chronic
heart failure
■ Using hospital based diagnoses without having the current
provider reviewing
■ Using an aftercare code when not appropriate – aftercare of
surgery not injury; encounter for other specified hospital
aftercare
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ICD-10-CM AND THE PDPM
Some common diagnoses which need additional information:
■MCA or CVA (any residuals? What, if any?)
■MCA or CVA with hemiplegia (left side? Right side?
Dominant? Non-dominant?)
■Heart Failure or HF (type? Acute? Chronic? Associated
problems?
■Pneumonia (cause? Type?)
■DM (Type 1? Type2? Any related conditions eg. Retinopathy,
vascular related conditions? Skin related conditions?)
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ICD-10-CM AND THE PDPM
OVERVIEW OF
THE
PDPM STRUCTURE
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ICD-10-CM AND THE PDPM
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MDS schedule
■ Calculations for PDPM payment are based on the
information contained in the 5-day MDS
■ Calculation would change only with the submission of an
Interim Patient Assessment (IPA) which reflects a change in
condition/category
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ICD-10-CM AND THE PDPM
ICD-10-CM AND THE PDPM
PT/OT
■ Utilizes the diagnosis in I0020B to identify the Clinical Category
■ The resident’s Function Score is then identified which then leads to the case mix index and the associated weight factor
■ The CMI weight factor is then multiplied times the PT/OT daily payment to identify the final payment for each day
■ Note: the CMI weight factor and daily payment rate are different for PT and OT
■ After the 20th day, daily rate decreases by 2% every 7 days
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ICD-10-CM AND THE PDPM
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IDENTIFY ICD-10-CM CODE
IDENTIFY FINAL
CLINICAL CATEGORY
IDENTIFY RESIDENT FUNCTION
SCORE
DETERMINE PDPM CMI
PT/OT under PDPM
ICD-10-CM AND THE PDPM
ST
■ Acute neurologic or not
■ Utilizes the cognitive score – BIMS/CPS
■ Utilizes specific diagnoses (Speech Comorbidities), part
check-off, part ICD-10-CM
■ Mechanically soft diet or difficulty swallowing
■ CMI multiplied times the daily ST rate provides the daily ST
rate
■ Rate remains the same throughout the stay
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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IDENTIFY ICD-10-CM CODE
IDENTIFY FINAL CLINICAL
CATEGORY
IDENTIFY COGNITIVE
FUNCTION AND COMORBIDITIES
SWALLOWING DISORDER OR MECHANICAL
ALTERED DIET?
DETERMINE PDPM CMI
ST under PDPM
ICD-10-CM AND THE PDPM
Nursing
■ Utilizes RUG categories however the number of terminal categories has been reduced from 43 to 21
■ Some diagnoses still impact the Nursing category assignment, e.g. Diabetes Mellitus, hemiplegia, Parkinson’s. etc. but pulled from the check-off
■ Function score will assist in determining the terminal category
■ Depression and Restorative Nursing still has an impact
■ CMI multiplied times the base rate for the daily rate
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ICD-10-CM AND THE PDPM■ Nursing
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ICD-10-CM AND THE PDPM■ Nursing
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ICD-10-CM AND THE PDPM■ Nursing
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ICD-10-CM AND THE PDPM
Non Therapy Ancillaries
■ Top 50 diagnoses which consume the most resources
■ HIV pulled from the billing form (UB-04) NOT the MDS
■ Some are from various areas of the MDS including, but not limited to, Section I Diagnoses
■ Points added and determines the CMI
■ CMI multiplied times the base rate
■ Receives 3 times the daily rate for the first 3 days of the stay then return to the daily rate
■ Stars in the following grids – Yellow = diagnoses pulled from I8000; Orange = may need additional diagnostic codes
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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IDENTIFY ICD-10-CM
CODE
IDENTIFY IF INCLUDED IN NTA LISTING
IDENTIFY POINTS TO
BE ALLOTTED
DETERMINE PDPM CMI
NTA under PDPM
ICD-10-CM AND THE PDPM
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Bed and Board
Non Case Mix
ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
CLINICAL
CATEGORY
MAPPING
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
DEFINING THE
DIAGNOSIS
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ICD-10-CM AND THE PDPM
■ Definitions of the various types of diagnoses were
established in the Universal Hospital Discharge Data Set
(UHDDS) (July 31, 1985; Federal Register)
■ Definitions apply to all health care organizations and levels
of care
■ Definitions can be found in the Coding Guidelines and
Medicare Benefit Policy Manual
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ICD-10-CM AND THE PDPM
PRINCIPAL DIAGNOSIS –
■ The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
■ Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc). The UHDDS definitions also apply to hospice services (all levels of care). (pg 107; ICD-10-CM Official Coding Guidelines for Coding and
Reporting)
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ICD-10-CM AND THE PDPM
OTHER DIAGNOSES
■ “all conditions that coexist at the time of admission, that
develop subsequently, or that affect the treatment received
and/or the length of stay. Diagnoses that relate to an earlier
episode which have no bearing on the current hospital stay
are to be excluded.” UHDDS definitions apply to inpatients in
acute care, short-term, long term care and psychiatric
hospital setting. ). (pg 107; ICD-10-CM Official Coding Guidelines for Coding and
Reporting)
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ICD-10-CM AND THE PDPM
PRIMARY DIAGNOSIS
■ First listed or that diagnosis to which the most resources are directed. In most cases the primary diagnosis is the same as the principal diagnosis but there may be circumstances when this may not be true
■ “It is important to note that this primary diagnosis represents the primary reason that the patient was admitted to the SNF which may or may not be the same reason that the patient was admitted to the qualifying hospital stay. In other words, there is no necessary reason that the primary SNF diagnosis must match the primary hospital diagnosis from the prior hospital stay. We would further note as illustrated in the ICD-10 crosswalk on the PDPM website, not all diagnoses are considered valid primary diagnoses for the SNF stay.” (pg 5, 12/11/18 SNF ODF Transcript)
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■ Post-hospital extended care services furnished to inpatients of
a SNF or a swing bed hospital are covered under the hospital
insurance program.
■ In addition, the beneficiary must require SNF care for a
condition that was treated during the qualifying hospital stay,
or for a condition that arose while in the SNF for treatment of a
condition for which the beneficiary was previously treated in
the hospital.Medicare Benefit Policy Manual pg. 4
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ICD-10-CM AND THE PDPM
ICD-10-CM AND THE PDPM
Determining the diagnosis
■ Must meet the criteria of the RAI Manual as well as the
Coding Guidelines
■ Must be documented by a provider (physician/nurse
practitioner/physician assistant) within the previous 60 days
■ Must be considered ‘active’ – diagnosis/es have a direct
relationship to the resident’s current functional, cognitive,
mood or behavior status, medical treatments, nursing
monitoring or risk of death during the look back period
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ICD-10-CM AND THE PDPM
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Recommended code = I0020B but refer to Manual when available
Reflect comorbidities
for Speech Therapy
and Non Therapy
Ancillaries
ICD-10-CM AND THE PDPM
Sources of the information
– Hospital information
– Transfer information
– History and physical
– Progress note/s
– Consult reports
– Surgical reports
– Diagnostic information e.g. labs, xrays, etc. can be used to assist in providing more specific diagnostic codes but NOT as the source of the diagnosis, e.g. UTI – lab identifies Ecoli bacteria
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ICD-10-CM AND THE PDPM
■ Primary reason for admission to be documented in I0020A
as a check off – used for the SNF QRP
■ Diagnostic code reflecting the reason for admission to be
documented in I0020B – used for the PDPM
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ICD-10-CM AND THE PDPM
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Used for the SNFQRP
Used for PDPM
ICD-10-CM AND THE PDPM
MDS 3.0 SECTIONS
EFFECTIVE 10/1/19
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
ACCESSING THE
INFORMATION ON THE
CLINICAL CATEGORY
MAPPING SPREAD SHEET
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ICD-10-CM AND THE PDPM
■ Be sure to use the most current Clinical Category Mapping
tool (Excel spreadsheet)
■ Utilize the search tool to locate the code; test it for accuracy
■ Use just the alpha-numeric when entering the code in the
search tool, no decimal points
■ Know that the computer will be programmed to perform the
search, just as it does for RUGs now (PCC has already updated
the system to reflect these PDPM related changes)
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
Provider related
■ Educate Providers on the new system and the need for
accurate, complete diagnostic information as well as the
timeframe for the MDS ARD
■ Establish a procedure for querying Providers when there is
insufficient diagnostic information (requires a written policy)
■ Determine if the Providers see the residents within a timely
manner for capturing the needed information for the 5 day
MDS
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ICD-10-CM AND THE PDPM
■ Attend education on how to accurately code with ICD-10-CM
■ Utilize a current ICD-10-CM coding manual when assigning diagnostic codes
■ Adhere to the requirements of the Coding Guidelines and Coding Clinic
■ Review current procedure, source, timeliness of obtaining diagnoses
■ Review current process, timeliness and accuracy for assigning the ICD-10-CM diagnostic code/s
■ Develop a policy on the coding process
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ICD-10-CM AND THE PDPM
■ Review current codes and clean the lists
■ Determine the primary diagnosis as a team and/or team consensus TEAMWORK AND COMMUNCIATION IS CRITICAL
■ Ensure the ENTIRE team is educated to the parameters of PDPM – Admissions, Social Services, Nursing staff, Activities, Dietary
■ Implement a review process such as Triple Check
■ Consider implementing a Clinical Documentation Integrity (CDI) process in the facility
■ Make sure there is a back-up educated individual in the facility for assigning the diagnostic codes
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ICD-10-CM AND THE PDPM
■ Consider incorporating diagnosis review along with the
admission drug regimen review
■ Evaluate the setting of the Assessment Reference Date
(ARD) due to the availability of the diagnostic information
■ Determine the diagnosis assignment for an Interim Patient
Assessment (IPA)
■ Therapy codes can still be listed on I8000 but determine
which would be the most appropriate codes to be in I8000
as there are a limited number of lines available and the ST
and NTA code identification should take precedent
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ICD-10-CM AND THE PDPM
■ Obtain as much ‘final’ information from the hospital as possible
■ Contact the hospital Medical Records Department for additional information, if needed
■ Do not include resolved conditions
■ Include ‘history of’ codes that have an impact on the resident’s current status
■ Z codes CAN be included on I8000 however surgical Z codes should not be there as identification of surgical aspects are identified in section J
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ICD-10-CM AND THE PDPM
■ Code to the highest level of specificity, avoid unspecified
codes as much as possible
■ Practice the assignment of the PDPM case mix to determine
potential problem areas in the system
■ Identify the most frequent primary diagnoses assigned and
determine if they would successfully flow through the system
■ Determine the value of the information provided at the time
of admission and what additional types of information would
be beneficial if available at admission
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ICD-10-CM AND THE PDPM
PRACTICE EXAMPLE
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ICD-10-CM AND THE PDPM
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ICD-10-CM AND THE PDPM
CMS PDPM web page
■ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html
Technical report
■ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html
CMS ICD-10-CM
■ https://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-CM.html
CODING PRACTICE BRIEFS
■ www.ahima.org (go to HIM Body Of Knowledge at bottom of page)
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