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REIMBURSEMENTANDICD-10 CODINGDecember 2018 - RB Health Partners, Inc.


ObjectivesØ Participants will learnØ The role of diagnosis coding in the PatientDriven Payment Model (PDPM).Ø The importance of correct diagnosisidentification and codingØ The impact of diagnosis coding on the revenuecycleØ How to prepare for increased importance ofdiagnosis coding with the implementation ofPDPM

Diagnoses and PDPM

Patient-Driven Payment Model(PDPM) OverviewPDPM uses clinical conditions to determine theresident’s payment category, rather than theamount of therapy provided.

PDPM OverviewPDPM is composed of five case mix adjustedpayment components and one non-case mixcomponent:q Physical Therapy (PT)q Occupational Therapy (OT)q Speech Language Pathology (SLP)q Nursingq Non-Therapy Ancillaries Services (NTA)q Non-Case Mix Component

PDPM Overview All residents will be classified into PT, OT, andSLP categories regardless of whether they are ontherapy case load.

PT and OT ComponentsØ PT and OT Case Mix are calculated in thesame manner, but paid separately based onseparate case-mix indices.Ø Drivers of PT and OT componentq Primary reason for skilled stay§ Utilizes diagnosis codes to classifyresidents into on of four PT and OT clinicalcategoriesq Function Score

PT and OT ComponentsSelecting of the primary reason for skilled stay:q Determine resident’s primary diagnosis§This code, or codes, must be entered into MDS ItemI8000.q Utilizing the primary diagnosis identify one of thefour clinical categories.§§§§Major joint replacement or spinal surgeryOther orthopedicNon-orthopedic surgeryMedical Management

PT and OT ComponentsSelecting of the primary reason for skilled stay:q Some codes may map to more than one clinicalcategoryq Further delineation may be made into a surgicalcategory based on specific procedures that occurredduring inpatient hospitalization§The ICD-10-PCS (procedure code), if utilized to mapthe resident into a surgical clinical category, must berecorded on the second line of item I8000.

PT and OT ComponentsMajor Joint Replacement or Spinal SurgeryICD-10-CM CodeDescriptionM970-Periprosthetic fracture around internal prosthetic hip jointM971-Periprosthetic fracture around internal prosthetic knee jointM973-Periprosthetic fracture around internal prosthetic shoulder jointS120-Unspecified displaced (or nondisplaced) fracture of first cervical vertebraS22001-Stable burst fracture of unspecified thoracic vertebraS32001-Stable burst fracture of unspecified lumbar vertebraT84010-Broken internal right hip prosthesisT84011-Broken internal left hip prosthesisT84012-Broken internal right knee prosthesisT84013-Broken internal left knee prosthesisZ471Aftercare following joint replacement surgery

PT and OT ComponentsPT and OT ClinicalCategoryMajor Joint Replacement orSpinal SurgeryOther OrthopedicPrimary Diagnosis ClinicalCategory Major Joint Replacement Spinal Surgery Orthopedic Surgery (ExceptMajor Joint Replacement orSpinal Surgery) Non-SurgicalOrthopedic/Musculoskeletal

PT and OT Clinical CategoriesPT and OT ClinicalCategoryNon-Orthopedic Surgery andAcute NeurologicMedical ManagementPrimary Diagnosis ClinicalCategoryNon-Orthopedic SurgeryAcute NeurologicAcute InfectionsCardiovascular andCoagulations Pulmonary Cancer Medical Management

16 PT and OT Case-Mix GroupsClinical CategoryFunction ScorePT Case Mix GroupCMIMajor Joint Replacement or Spinal Surgery0-5TA1.53Major Joint Replacement or Spinal Surgery6-9TB1.69Major Joint Replacement or Spinal Surgery10-23TC1.88Major Joint Replacement or Spinal Surgery24TD1.92Other Orthopedic0-5TE1.42Other Orthopedic6-9TF1.61Other Orthopedic10-23TG1.67Other Orthopedic24TH1.16Medical Management0-5TI1.13Medical Management6-9TJ1.42Medical Management10-23TK1.52Medical Management24TL1.09Non-Orthopedic Surgery and Acute Neurologic0-5TM1.27Non-Orthopedic Surgery and Acute Neurologic6-9TN1.48Non-Orthopedic Surgery and Acute Neurologic10-23TO1.55Non-Orthopedic Surgery and Acute Neurologic24TP1.08

SLP ComponentØ ST Case Mix utilizes diagnosis codes to classifyresidents into neurologic or non-neurologicclinical categoryq It also utilizes diagnosis coding to capture SLPrelated comorbidities.§Oral Cancers§Speech Language Deficits

SLP ComponentØ Five Characteristics that will impact the SLPComponentq Acute Neurologic or Non-Neurologicq SLP-Related Comorbidityq Cognitive Impairmentq Mechanically Altered Dietq Swallowing Disorder

SLP ComponentThe following comorbidities will be pulled fromSection I – Active Conditions of the MDSØ Item I4300. AphasiaØ Item I4500. CVA, TIA, StrokeØ Item I4900. Hemiplegia or HemiparesisØ Item I5500. Traumatic Brain Injury

SLP ComponentThe following comorbidities will be pulled fromSection I – Active Conditions of the MDSØ Item I8000.q Laryngeal Cancerq Apraxiaq Dysphagiaq ALSq Oral Cancersq Speech and Language Deficits

SLP ComponentConditionICD-10-CMCodeDescriptionSpeech and LanguageDeficitsI69.928Other speech and language deficits following unspecified cerebrovasculardiseaseSpeech and LanguageDeficitsI69.920Aphasia following unspecified cerebrovascular diseaseSpeech and LanguageDeficitsI69.921Dysphasia following unspecified cerebrovascular diseaseSpeech and LanguageDeficitsI69.922Dysarthria following unspecified cerebrovascular diseaseSpeech and LanguageDeficitsI69.923Fluency disorder following unspecified cerebrovascular diseaseSpeech and LanguageDeficitsI69.928Other speech and language deficits following unspecified cerebrovasculardisease

SLP ComponentAdditional factors utilized to adjust case mix indexcalculationØ Mechanically Altered Dietq Determined by K0510C2Ø Swallowing Disorderq Determined by K0100Ø Cognitive Impairmentq Determined by C0500 or C1000

12 SLP Case-Mix GroupsPresence of Acute NeurologicCondition, SLP-RelatedComorbidity, or CognitiveImpairmentMechanicallySLP Case Mix GroupAltered Diet orSwallowing thSC2.66Any oneNeitherSD1.46Any oneEitherSE2.33Any oneBothSF2.97Any twoNeitherSG2.04Any twoEitherSH2.85Any twoBothSI3.51All threeNeitherSJ2.98All threeEitherSK3.69All threeBothSL4.19

Nursing ComponentØ Utilizes modified version of the RUG-IV NursingCategoriesq Reduced to 25 PDPM RUGS from the original 43q Diagnosis codes are used to further classifyresidents into one of the 25 PDPM RUG groups.Ø Nursing Function Score based on Section GG

Nursing ComponentØ Further division is based on the presence of thefollowing conditions or services:q Tracheostomy and Ventilator/Respiratorq Infection Isolationq Depressionq Restorative Nursing Services

Nursing ComponentØ RUGs are grouped into six categoriesq Extensive Servicesq Special Care Highq Special Care Lowq Clinically Complexq Behavioral Cognitive Symptomsq Reduced Physical FunctionØ Three categories utilize diagnosis and codingfrom section I of the MDS.

Nursing ComponentØ Special Care HighØ Diagnosis Coding in from Section Iq Septicemia (I2100)q Diabetes (I2900) with both of the following§§(N0350A) Insulin injections all 7 days(N0350B) Insulin order changes on 2 or moredays

Nursing ComponentØ Special Care HighØ Diagnosis Coding in from Section Iq Quadriplegia (I5100) with§Nursing Function Score greater than or equal toeleven (11)q COPD (I6200) and§J1100C SOB when lying flat

Nursing ComponentØ Special Care Highq Fever (J1550A) and one of the following:q Pneumonia (I2000)q Vomiting (J1550B)q Weight Loss (K0300, 1 or 2)q Feeding Tube (K0510B1 or K0510B2)

Nursing ComponentØ Special Care Lowq Diagnosis Codingq Cerebral palsy (I4400) and§Nursing Function Score of 11 or greaterq Multiple Sclerosis (I5200) and§Nursing Function Score of 11 or greaterq Parkinson's (I5300) and§Nursing Function Score of 11 or greaterq Respiratory Failure (I6300) and§Oxygen therapy while a resident (0100C2)

Nursing ComponentØ Clinically Complexq Diagnosis Codingq Pneumonia (I2000) and§Nursing Function Score of 11 or greater

Nursing Case Mix Groups

Non-Therapy Ancillary (NTA)ComponentØ Utilizes 50 diagnosis codes and extensiveservices to identify additional comorbiditiesØ Must be coded on the UB04 or MDSØ Utilizes a points scale from 1 to 8 to calculatecomorbidity score

NTA ComponentØ The following conditions will be pulled fromSection I – Active Conditions of the MDS.Ø Multiple Sclerosis (I5200)Ø Asthma, COPD, Chronic Lung Disease (I6200)Ø Wound Infections (I2500)Ø Diabetes Mellitus (DM) (I2900)Ø Multi-Drug Resistant Organism (MDRO) (I1700)Ø Malnutrition (I5600)

NTA ComponentØ The following conditions will be pulled fromSection I – Active Conditions of the MDS.Ø I8000 – Additional Diagnosesq Lung Transplant Statusq Major Organ Transplant Status, Except Lungq Opportunistic Infectionsq Bone, Joint, Muscle Infections/Necrosis, ExceptAseptic Necrosis of Boneq Chronic Myeloid Leukemiaq Endocarditis

NTA ComponentØ The following conditions will be pulled fromSection I – Active Conditions of the MDS.Ø I8000 – Additional Diagnosesq Immune Disordersq End-Stage Liver Diseaseq Narcolepsy and Cataplexyq Cystic Fibrosisq Specified Hereditary Metabolic and ImmuneDisordersq Morbid Obesity

NTA ComponentØ The following conditions will be pulled fromSection I – Active Conditions of the MDS.Ø I8000 – Additional Diagnosesq Psoriatic Arthropathy and Systemic Sclerosisq Chronic Pancreatitisq Proliferative Diabetic Retinopathy and VitreousHemorrhageq Complications of Specified Implanted Device orGraftq Inflammatory Bowel Disease

NTA ComponentØ The following conditions will be pulled fromSection I – Active Conditions of the MDS.Ø I8000 – Additional Diagnosesq Aseptic Necrosis of Boneq Cardio-Respiratory Failure and Shockq Myelodysplastic Syndromes and Myelofibrosisq Systemic Lupus Erythematosus, OtherConnective Tissue Disorders, and InflammatoryHemorrhageq Severe Skin Burn or Condition

NTA ComponentØ The following conditions will be pulled fromSection I – Active Conditions of the MDS.Ø I8000 – Additional Diagnosesq Diabetic Retinopathy, Except ProliferativeqqqqqDiabetic Retinopathy and Vitreous HemorrhageIntractable EpilepsyDisorders of ImmunityCirrhosis of LiverRespiratory ArrestPulmonary Fibrosis & Other Lung Disorders

NTA ComponentComorbidity DescriptionICD-10-CM CodeICD-10-CM Code DescriptionEndocarditisA0102Typhoid fever with heart involvementEndocarditisA1884Tuberculosis of heartEndocarditisA3282Listerial endocarditisEndocarditisA3951Meningococcal endocarditisEndocarditisA5203Syphilitic endocarditisEndocarditisA78Q feverEndocarditisB3321Viral endocarditisEndocarditisB376Candidal endocarditisEndocarditisI330Acute and subacute infective endocarditisEndocarditisI339Acute and subacute endocarditis, unspecifiedEndocarditisI38Endocarditis, valve unspecifiedEndocarditisI39Endocarditis and heart valve disorders in diseases classified elsewhereEndocarditisM3211Endocarditis in systemic lupus erythematosus

NTA ComponentØ HIV/AIDS add-onØ Applied based on the presence of ICD-10-CMcode B20 on the SNF claim.Ø Due to the significant increase in nursing cost tocare for HIV/AIDS patients, the facility will get an18% increase in NTA category.

NTA Case Mix GroupsNTA Comorbidity ScoreNTA Case Mix GroupCMI12 NA3.259-11NB2.536-8NC1.853-5ND1.341-2NE0NF0.960.72

Coding Pitfalls and Tips

Principal DiagnosisØ The Principal Diagnosis: is defined in theUniform Hospital Discharge Data Set (UHDDS) as“that condition established after study to bechiefly responsible for occasioning theadmission of the patient to the hospital forcare”.Ø This definition has been expanded to include ALLnon-outpatient settings including SNFs / LTCfacilities.

Principal Diagnosis43Ø When a patient is treated for an acutecondition in the hospital and transferred to aSNF for rehabq The acute condition, if still present is coded as thefirst listed/principal diagnosis.q The aftercare is coded as the first listed/principaldiagnosis, if the acute condition is no longerpresent.

Principal Diagnosis44Ø When a patient transitions to long term careor returns from hospital stay for continuedlong term careq The chronic condition, that requires continued stayfor long term care is the first listed/principaldiagnosis.q The acute condition or aftercare is sequenced as thefirst additional/secondary diagnosis.

Additional Diagnoses45Ø Secondary/Additional Diagnoses – conditions thatcoexist at the time of admission, that developsubsequently during the resident’s stay or thataffect the treatment the resident receives or theresident’s length of stay.q Diagnosis that support both the Principle Dx. Thisis where you would include the therapy treatmentdiagnosis codes as they support the Admit Dx

Additional Diagnoses46Ø Medicare Claims Processing Manual, Chapter Six,page 33, indicates the Principal Diagnosis and upto eight additional diagnosis codes are included inthe claims review process.Ø This makes it imperative to get the most pertinentdiagnoses requiring skilled services in the top 8boxes of this section.

Common Coding Errors47Ø Incorrect selection of principal diagnosisØ Coding and Sequencing of Hypertension (HTN)with Chronic kidney disease (CKD)Ø Coding External Causes (V00-Y99)Ø Coding UTI without meeting all of the criteriaper the Resident Assessment Instrument (RAI)Manual

Common Coding Errors48Ø Coding Aftercare codes (Z codes) with injury orfracture codes with a 7th character thatidentifies the encounter typeØ Incorrect 7th character selection for injury andfracture codes to identify the encounter typeØ Coding conditions to a lower or higher level ofspecificity than provider documentationsupports

Common Coding Errors49Ø Coding acute condition, when conditions isresolved and skilled care is focused on thesequela or aftercareØ Coding symptoms with presence of adefinitive diagnosis

Risks of Inaccurate Coding

Risks of Incorrect Coding51Ø Inaccurate health recordØ Incomplete or inaccurate data on the MDSØ Incomplete or inaccurate data on the UB04

Inaccurate Health Record52Ø Risk ManagementØ Diagnosis of osteoporosis in a resident thatobtains a fracture after rolling out of the bed inlowest position onto fall mats.q Coding guidelines indicate that the fracture maybe coded as a pathologic fracture.Ø Quality CareØ Resident specific care based in part on theirspecific diagnoses and other care needs.

Incomplete/Inaccurate MDS53Ø Care PlanningØ Diagnoses aid in identification of problems anddetermination of interventionsØ Quality MeasuresØ Percentage of Short Stay Residents with PressureUlcers that are New or Worseningq Includes Covariates related to diabetes orperipheral vascular disease coded in Section I

Incomplete/Inaccurate UB54Ø Claims DenialsØ Remittance advice informs of invalid diagnosis,but does not specify which code or sequenceØ Quality MeasuresØ SNF Readmission Measure (SNFRM)q Exclusions include hospitalized for primarydiagnosis related to medical (non-surgical)treatment of cancer


What’s Next56Ø Complete routine coding and MDS auditsØ Ensure staff have current ICD-10-CM codebooksØ Updated every October 1stØ Provide staff with basic ICD-10-CM trainingØ Provide staff with PDPM training

What’s Next57Ø Ensure that all disciplines are utilizing thesame primary diagnosisØ Review diagnosis coding during Triple Check(Pre-Bill) meetingØ Review code updates effective October 1st andrevise codes for current residents, as needed


Thank you for your participationTo learn more about this topic please contactHeather Py, RHIT, CCS, CHPS, RAC-CT, Director ofHealth Information Management may also contact Robin A. Bleier, President withregard to this or other services or call us at727.786.3032.2018 RB Health Partners, Inc.

qRespiratory Failure (I6300) and § Oxygen therapy while a resident (0100C2) Nursing Component . care for HIV/AIDS patients, the facility will get an 18% increase in NTA category. NTA Case Mix Groups NTA Comorbidity Score NTA Case Mix Group CMI 12 NA 3.25 9-11 NB 2.53 6-8 NC 1.85

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