ICD-10-CM AND THE PDPM - Paanac

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ICD-10-CMANDTHE PDPMMary Ann P. Leonard, RHIA, RAC-CTHealth Information Professionalsmalhip@yahoo.com

ICD-10-CM AND THE PDPMOBJECTIVES To understand how the ICD-10-CM codes are utilized by thenew payment system To understand how the Clinical Category Mapping is utilized To understand in which ‘buckets’ of the PDPM the diagnosticcode is being used To provide recommendations related to the best utilizationof the ICD-10-CM codesHealth Information Professionals2

ICD-10-CM AND THE PDPMICD-10-CM SOURCEHealth Information Professionals3

ICD-10-CM AND THE PDPMWhere does the International Classification of Disease, ClinicalModification (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 completedHealth Information Professionals4

ICD-10-CM AND THE PDPMSources for criteria for assigning the ICD-10-CM codes Coding Guidelines published by CDC, DHHS/CMS Coding Clinic published by the American HospitalAssociation– Managed by the Cooperating Parties – AmericanHospital Association, American Health InformationAssociation, National Center for Health Statistics,Centers for Medicare/Medicaid Services– Question and answer format, questions/situationssubmitted by multiple sourcesHealth Information Professionals5

ICD-10-CM AND THE PDPMWhat was the impact of ICD-10-CM in the past? ICD-10-CM codes were not utilized under RUGs as a directimpact on reimbursement Diagnoses which impacted RUGs were primarily check-offsin section I, e.g. hemiplegia, Diabetes Mellitus orincorporated in other section of the MDS e.g. Section O fortrach/vent care Under PDPM there is a direct relationship between the codeassignment and payment categoriesHealth Information Professionals6

ICD-10-CM AND THE PDPMFactors which impact ICD-10-CM code assignment Information provided from acute care – ranges from nothingto 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 careHealth Information Professionals7

POLICY AND PROCEDUREEvery facility should have a policy/procedure on diagnosticcode assignmentSome 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 Provider8

CODING WITH ICD-10-CM AND THE MDS (ACCORDING TO THE PA RAICOORDINATOR)Coding diagnoses in Section I is not based on ICD codes.Alzheimer's, Huntingdon's, and Parkinson’s disease each have acorresponding item on the MDS, and would be coded if the criteria statedin the RAI User’s Manual are met.The basics of coding a diagnosis include: The disease conditions in Section I require a physician documenteddiagnosis in the resident's medical record such as in: physician progressnotes, 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 thephysician should be entered.

CODING WITH ICD-10-CM AND THE MDSCoding diagnoses in Section I is not based on ICD codes (cont.) Diagnoses communicated verbally must be documented in the medical record by thephysician to ensure follow-up. Diagnostic information, including past history obtained from family members and closecontacts, must also be documented in the medical record by the physician to ensurevalidity and follow-up. Once a diagnosis is identified, it must be determined if the diagnosis is active. Activediagnoses 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 ofdeath during the 7-day look-back period. Conditions that have been resolved, do not affect the resident’s current status, or do notdrive the Resident’s plan of care during the 7-day look-back period, are considered inactivediagnoses, and are not coded on the MDS.Pennsylvania RAI Coordinator

ICD-10-CM AND THE PDPMSome coding rules which directly impact SNF code assignment Diagnoses must be documented by the provider within thelast 60 days ( of the ARD) and active within the last 7 days(RAI Manual) Infections which were treated in the hospital and treatmentis completed before they arrive at the SNF, the infectioncannot be coded (e.g. UTI, Pneumonia, Sepsis, etc.) Long term residents who return after a hospital admissionmust be coded to the reason why they are long term (e.gAlzheimer's, dementia, Parkinson's, MS, CVA with sequela,etc.)Health Information Professionals11

ICD-10-CM AND THE PDPMSome coding rules which directly impact SNF code assignment Use of 7th character to identify the episode of care stillapplies– A – initial (acute) episode of care (diagnostic)– D – subsequent episode of care (treatment)– S – sequela episode of care (residual from previousinjury or trauma Stroke related codes are I69 not I63, etc.Health Information Professionals12

ICD-10-CM AND THE PDPMSome implications with the Clinical Category Mapping Most rehab codes will not be accepted as the primarydiagnosis – “Return to Provider” Lack of specificity in code assignment could generate a“Return to Provider” response Secondary diagnoses will impact the final payment throughthe 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 checkoff, in order to receive the designated point/sHealth Information Professionals13

ICD-10-CM AND THE PDPMSome diagnostic codes which are “Return to Provider” whenprimary (under a recent vendor study “Return to Provider” codes were @ 10% of the primary diagnoses) M62.81 Muscle weakness Z87.01Personal History of pneumonia Z51.81Encounter for other specified aftercare Z48.89Encounter for other specified surgical aftercare S82.486D Nondisplaced transverse fracture of shaft ofunspecified fibula, routine healing R62.7Adult failure to thrive R53.1WeaknessHealth Information Professionals14

ICD-10-CM AND THE PDPMSome diagnostic codes which are “Return to Provider” whenprimary R53.2Functional quadriplegia R53.81Malaise R54Age related debility R41.82Altered mental status R41.81Age related cognitive decline R29.6Repeated falls R27.9Unspecified lack of coordinationHealth Information Professionals15

ICD-10-CM AND THE PDPMSome diagnostic codes which are “Return to Provider” whenprimary R26.9Unspecified abnormalities of gait R13.--Dysphagia (all phases) I69.369 Other paralytic syndrome following cerebralinfarction affecting unspecified side I69.359 Hemiplegia and hemiparesis following cerebralinfarction affecting unspecified side K92.2Gastrointestinal hemorrhage, unspecifiedHealth Information Professionals16

ICD-10-CM AND THE PDPMSome diagnostic codes which are “Medical Management” or“Acute Neurologic” when primary R26.0Ataxic gait R26.1Paralytic gait R26.89Other abnormalities of gait and mobility(Nonsurgical orthopedic/Musculoskeltal) R27.0Ataxia, unspecified R27.8Other lack of coordination R29.1MeningismusHealth Information Professionals17

ICD-10-CM AND THE PDPMSome diagnostic codes which are “Medical Management” or“Acute Neurologic” when primary R29.818Other symptoms and signs involving thenervous system R29.898Other symptoms and signs involving themusculoskeletal system R40.3Persistent vegetative state R41.44Neurologic neglect syndrome R41.842Visuospatial deficitHealth Information Professionals18

ICD-10-CM AND THE PDPMSome diagnostic codes which are “Medical Management” or“Acute Neurologic” when primary R47.01Aphasia R47.02Dysphasia R47.1Dysarthria and anarthria R47.89Other speech disturbances R48.2Apraxia R53.0Neoplastic (malignant) related fatigueHealth Information Professionals19

ICD-10-CM AND THE PDPMFive mistakes often made selecting ICD-10-CM codes in theSNF 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 ProviderSOURCE: Jessie McGill, AANAC newsletterHealth Information Professionals20

ICD-10-CM AND THE PDPMOther mistakes often made selecting ICD-10-CM codes in theSNF Using multiple single codes when a one i.e. a “combinationcode”, will do (acute on chronic codes) e.g. acute on chronicheart failure Using hospital based diagnoses without having the currentprovider reviewing Using an aftercare code when not appropriate – aftercare ofsurgery not injury; encounter for other specified hospitalaftercareHealth Information Professionals21

ICD-10-CM AND THE PDPMSome 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? Associatedproblems? Pneumonia (cause? Type?) DM (Type 1? Type2? Any related conditions eg. Retinopathy,vascular related conditions? Skin related conditions?)Health Information Professionals22

ICD-10-CM AND THE PDPMOVERVIEW OFTHEPDPM STRUCTUREHealth Information Professionals23

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ICD-10-CM AND THE PDPMMDS schedule Calculations for PDPM payment are based on theinformation contained in the 5-day MDS Calculation would change only with the submission of anInterim Patient Assessment (IPA) which reflects a change incondition/categoryHealth Information Professionals25

ICD-10-CM AND THE PDPMPT/OT Utilizes the diagnosis in I0020B to identify the ClinicalCategory The resident’s Function Score is then identified which thenleads to the case mix index and the associated weight factor The CMI weight factor is then multiplied times the PT/OTdaily payment to identify the final payment for each day Note: the CMI weight factor and daily payment rate aredifferent for PT and OT After the 20th day, daily rate decreases by 2% every 7 daysHealth Information Professionals26

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ICD-10-CM AND THE PDPMPT/OT under PDPMIDENTIFY ICD10-CM CODEIDENTIFYFINALCLINICALCATEGORYHealth Information EPDPM CMI28

ICD-10-CM AND THE PDPMST Acute neurologic or not Utilizes the cognitive score – BIMS/CPS Utilizes specific diagnoses (Speech Comorbidities), partcheck-off, part ICD-10-CM Mechanically soft diet or difficulty swallowing CMI multiplied times the daily ST rate provides the daily STrate Rate remains the same throughout the stayHealth Information Professionals29

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ICD-10-CM AND THE PDPMST under PDPMIDENTIFY ICD10-CM CODEIDENTIFY FINALCLINICALCATEGORYHealth Information ProfessionalsIDENTIFYCOGNITIVEFUNCTION ANDCOMORBIDITIESSWALLOWINGDISORDER ORMECHANICALALTERED DIET?DETERMINEPDPM CMI31

ICD-10-CM AND THE PDPMNursing Utilizes RUG categories however the number of terminalcategories has been reduced from 43 to 21 Some diagnoses still impact the Nursing categoryassignment, e.g. Diabetes Mellitus, hemiplegia, Parkinson’s.etc. but pulled from the check-off Function score will assist in determining the terminalcategory Depression and Restorative Nursing still has an impact CMI multiplied times the base rate for the daily rateHealth Information Professionals32

ICD-10-CM AND THE PDPM NursingHealth Information Professionals33

ICD-10-CM AND THE PDPM NursingHealth Information Professionals34

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ICD-10-CM AND THE PDPMNon 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 limitedto, 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 thenreturn to the daily rate Stars in the following grids – Yellow diagnoses pulled from I8000; Orange may need additionaldiagnostic codesHealth Information Professionals36

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ICD-10-CM AND THE PDPMNTA under PDPMIDENTIFYICD-10-CMCODEIDENTIFY IFINCLUDED INNTA LISTINGHealth Information ProfessionalsIDENTIFYPOINTS TOBE ALLOTTEDDETERMINEPDPM CMI42

ICD-10-CM AND THE PDPMNon Case MixBed andBoardHealth Information Professionals43

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ICD-10-CM AND THE PDPMCLINICALCATEGORYMAPPINGHealth Information Professionals45

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ICD-10-CM AND THE PDPMDEFINING THEDIAGNOSISHealth Information Professionals49

ICD-10-CM AND THE PDPM Definitions of the various types of diagnoses wereestablished in the Universal Hospital Discharge Data Set(UHDDS) (July 31, 1985; Federal Register) Definitions apply to all health care organizations and levelsof care Definitions can be found in the Coding Guidelines andMedicare Benefit Policy ManualHealth Information Professionals50

ICD-10-CM AND THE PDPMPRINCIPAL DIAGNOSIS – The principal diagnosis is defined in the Uniform HospitalDischarge Data Set (UHDDS) as “that condition establishedafter study to be chiefly responsible for occasioning theadmission of the patient to the hospital for care.” Since that time the application of the UHDDS definitions hasbeen expanded to include all non-outpatient settings (acutecare, short term, long term care and psychiatric hospitals;home health agencies; rehab facilities; nursing homes, etc).The UHDDS definitions also apply to hospice services (alllevels of care). (pg 107; ICD-10-CM Official Coding Guidelines for Coding andReporting)Health Information Professionals51

ICD-10-CM AND THE PDPMOTHER DIAGNOSES “all conditions that coexist at the time of admission, thatdevelop subsequently, or that affect the treatment receivedand/or the length of stay. Diagnoses that relate to an earlierepisode which have no bearing on the current hospital stayare to be excluded.” UHDDS definitions apply to inpatients inacute care, short-term, long term care and psychiatrichospital setting. ).(pg 107; ICD-10-CM Official Coding Guidelines for Coding andReporting)Health Information Professionals52

ICD-10-CM AND THE PDPMPRIMARY DIAGNOSIS First listed or that diagnosis to which the most resources aredirected. In most cases the primary diagnosis is the same as theprincipal diagnosis but there may be circumstances when thismay not be true “It is important to note that this primary diagnosis represents theprimary reason that the patient was admitted to the SNF whichmay or may not be the same reason that the patient wasadmitted to the qualifying hospital stay. In other words, there isno necessary reason that the primary SNF diagnosis must matchthe primary hospital diagnosis from the prior hospital stay. Wewould further note as illustrated in the ICD-10 crosswalk on thePDPM website, not all diagnoses are considered valid primarydiagnoses for the SNF stay.” (pg 5, 12/11/18 SNF ODF Transcript)Health Information Professionals53

ICD-10-CM AND THE PDPM Post-hospital extended care services furnished to inpatients ofa SNF or a swing bed hospital are covered under the hospitalinsurance program. In addition, the beneficiary must require SNF care for acondition that was treated during the qualifying hospital stay,or for a condition that arose while in the SNF for treatment of acondition for which the beneficiary was previously treated inthe hospital.Medicare Benefit Policy Manual pg. 4Health Information Professionals54

ICD-10-CM AND THE PDPMDetermining the diagnosis Must meet the criteria of the RAI Manual as well as theCoding Guidelines Must be documented by a provider (physician/nursepractitioner/physician assistant) within the previous 60 days Must be considered ‘active’ – diagnosis/es have a directrelationship to the resident’s current functional, cognitive,mood or behavior status, medical treatments, nursingmonitoring or risk of death during the look back periodHealth Information Professionals55

ICD-10-CM AND THE PDPMRecommended code I0020B but refer to Manual when availableReflect comorbiditiesfor Speech Therapyand Non TherapyAncillariesHealth Information Professionals56

ICD-10-CM AND THE PDPMSources of the information–––––––Hospital informationTransfer informationHistory and physicalProgress note/sConsult reportsSurgical reportsDiagnostic information e.g. labs, xrays, etc. can be usedto assist in providing more specific diagnostic codesbut NOT as the source of the diagnosis, e.g. UTI – labidentifies Ecoli bacteriaHealth Information Professionals57

ICD-10-CM AND THE PDPM Primary reason for admission to be documented in I0020Aas a check off – used for the SNF QRP Diagnostic code reflecting the reason for admission to bedocumented in I0020B – used for the PDPMHealth Information Professionals58

ICD-10-CM AND THE PDPMUsed for the SNFQRPUsed for PDPMHealth Information Professionals59

ICD-10-CM AND THE PDPMMDS 3.0 SECTIONSEFFECTIVE 10/1/19Health Information Professionals60

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ICD-10-CM AND THE PDPMACCESSING THEINFORMATION ON THECLINICAL CATEGORYMAPPING SPREAD SHEETHealth Information Professionals68

ICD-10-CM AND THE PDPM Be sure to use the most current Clinical Category Mappingtool (Excel spreadsheet) Utilize the search tool to locate the code; test it for accuracy Use just the alpha-numeric when entering the code in thesearch tool, no decimal points Know that the computer will be programmed to perform thesearch, just as it does for RUGs now (PCC has already updatedthe system to reflect these PDPM related changes)Health Information Professionals69

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ICD-10-CM AND THE PDPMProvider related Educate Providers on the new system and the need foraccurate, complete diagnostic information as well as thetimeframe for the MDS ARD Establish a procedure for querying Providers when there isinsufficient diagnostic information (requires a written policy) Determine if the Providers see the residents within a timelymanner for capturing the needed information for the 5 dayMDSHealth Information Professionals71

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 assigningdiagnostic codes Adhere to the requirements of the Coding Guidelines andCoding Clinic Review current procedure, source, timeliness of obtainingdiagnoses Review current process, timeliness and accuracy forassigning the ICD-10-CM diagnostic code/s Develop a policy on the coding processHealth Information Professionals72

ICD-10-CM AND THE PDPM Review current codes and clean the lists Determine the primary diagnosis as a team and/or teamconsensus TEAMWORK AND COMMUNCIATION IS CRITICAL Ensure the ENTIRE team is educated to the parameters ofPDPM – 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 thefacility for assigning the diagnostic codesHealth Information Professionals73

ICD-10-CM AND THE PDPM Consider incorporating diagnosis review along with theadmission 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 PatientAssessment (IPA) Therapy codes can still be listed on I8000 but determinewhich would be the most appropriate codes to be in I8000as there are a limited number of lines available and the STand NTA code identification should take precedentHealth Information Professionals74

ICD-10-CM AND THE PDPM Obtain as much ‘final’ information from the hospital aspossible Contact the hospital Medical Records Department foradditional information, if needed Do not include resolved conditions Include ‘history of’ codes that have an impact on theresident’s current status Z codes CAN be included on I8000 however surgical Z codesshould not be there as identification of surgical aspects areidentified in section JHealth Information Professionals75

ICD-10-CM AND THE PDPM Code to the highest level of specificity, avoid unspecifiedcodes as much as possible Practice the assignment of the PDPM case mix to determinepotential problem areas in the system Identify the most frequent primary diagnoses assigned anddetermine if they would successfully flow through the system Determine the value of the information provided at the timeof admission and what additional types of information wouldbe beneficial if available at admissionHealth Information Professionals76

ICD-10-CM AND THE PDPMPRACTICE EXAMPLEHealth Information Professionals77

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ICD-10-CM AND THE PDPMCMS PDPM web page icePayment/SNFPPS/PDPM.htmlTechnical report icePayment/SNFPPS/therapyresearch.htmlCMS ICD-10-CM -10CM.htmlCODING PRACTICE BRIEFS www.ahima.org (go to HIM Body Of Knowledge at bottom of page)Health Information Professionals79

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: