REIMBURSEMENTAND

ICD-10 CODING

December 2018 - RB Health Partners, Inc.

Objectives

Objectives

Ø Participants will learn Ø The role of diagnosis coding in the Patient

Driven Payment Model (PDPM).Ø The importance of correct diagnosis

identification and codingØ The impact of diagnosis coding on the revenue

cycleØ How to prepare for increased importance of

diagnosis coding with the implementation of PDPM

Diagnoses and PDPM

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

PDPM Overview

PDPM is composed of five case mix adjusted payment components and one non-case mix component:

q Physical Therapy (PT) q Occupational Therapy (OT) q Speech Language Pathology (SLP) q Nursing q Non-Therapy Ancillaries Services (NTA)q Non-Case Mix Component

PDPM Overview

• All residents will be classified into PT, OT, and SLP categories regardless of whether they are on therapy case load.

PT and OT Components

Ø PT and OT Case Mix are calculated in the same manner, but paid separately based on separate case-mix indices.

Ø Drivers of PT and OT componentq Primary reason for skilled stay

§ Utilizes diagnosis codes to classify residents into on of four PT and OT clinical categories

q Function Score

PT and OT Components

Selecting of the primary reason for skilled stay:

q Determine resident’s primary diagnosis

§ This code, or codes, must be entered into MDS Item

I8000.

q Utilizing the primary diagnosis identify one of the

four clinical categories.

§ Major joint replacement or spinal surgery

§ Other orthopedic

§ Non-orthopedic surgery

§ Medical Management

PT and OT Components

Selecting of the primary reason for skilled stay: q Some codes may map to more than one clinical

category q Further delineation may be made into a surgical

category based on specific procedures that occurred during inpatient hospitalization§ The ICD-10-PCS (procedure code), if utilized to map

the resident into a surgical clinical category, must be recorded on the second line of item I8000.

PT and OT ComponentsMajor Joint Replacement or Spinal Surgery

ICD-10-CM Code DescriptionM970- Periprosthetic fracture around internal prosthetic hip joint

M971- Periprosthetic fracture around internal prosthetic knee joint

M973- Periprosthetic fracture around internal prosthetic shoulder joint

S120- Unspecified displaced (or nondisplaced) fracture of first cervical vertebra

S22001- Stable burst fracture of unspecified thoracic vertebra

S32001- Stable burst fracture of unspecified lumbar vertebra

T84010- Broken internal right hip prosthesis

T84011- Broken internal left hip prosthesis

T84012- Broken internal right knee prosthesis

T84013- Broken internal left knee prosthesis

Z471 Aftercare following joint replacement surgery

PT and OT Components

PT and OT Clinical Category

Primary Diagnosis Clinical Category

Major Joint Replacement or Spinal Surgery

• Major Joint Replacement• Spinal Surgery

Other Orthopedic • Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

• Non-Surgical Orthopedic/Musculoskeletal

PT and OT Clinical Categories

PT and OT Clinical Category

Primary Diagnosis Clinical Category

Non-Orthopedic Surgery and Acute Neurologic

• Non-Orthopedic Surgery• Acute Neurologic

Medical Management • Acute Infections• Cardiovascular and

Coagulations• Pulmonary• Cancer• Medical Management

16 PT and OT Case-Mix GroupsClinical Category Function Score PT Case Mix Group CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 1.53Major Joint Replacement or Spinal Surgery 6-9 TB 1.69Major Joint Replacement or Spinal Surgery 10-23 TC 1.88Major Joint Replacement or Spinal Surgery 24 TD 1.92Other Orthopedic 0-5 TE 1.42Other Orthopedic 6-9 TF 1.61Other Orthopedic 10-23 TG 1.67Other Orthopedic 24 TH 1.16Medical Management 0-5 TI 1.13Medical Management 6-9 TJ 1.42Medical Management 10-23 TK 1.52Medical Management 24 TL 1.09Non-Orthopedic Surgery and Acute Neurologic 0-5 TM 1.27Non-Orthopedic Surgery and Acute Neurologic 6-9 TN 1.48Non-Orthopedic Surgery and Acute Neurologic 10-23 TO 1.55Non-Orthopedic Surgery and Acute Neurologic 24 TP 1.08

SLP Component

Ø ST Case Mix utilizes diagnosis codes to classify residents into neurologic or non-neurologic clinical category q It also utilizes diagnosis coding to capture SLP

related comorbidities.§ Oral Cancers§ Speech Language Deficits

SLP Component

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

SLP Component

The following comorbidities will be pulled from Section 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 Component

The following comorbidities will be pulled from Section I – Active Conditions of the MDSØ Item I8000.

q Laryngeal Cancerq Apraxiaq Dysphagiaq ALSq Oral Cancersq Speech and Language Deficits

SLP Component

Condition ICD-10-CM Code Description

Speech and Language Deficits I69.928 Other speech and language deficits following unspecified cerebrovascular

disease

Speech and Language Deficits I69.920 Aphasia following unspecified cerebrovascular disease

Speech and Language Deficits I69.921 Dysphasia following unspecified cerebrovascular disease

Speech and Language Deficits I69.922 Dysarthria following unspecified cerebrovascular disease

Speech and Language Deficits I69.923 Fluency disorder following unspecified cerebrovascular disease

Speech and Language Deficits I69.928 Other speech and language deficits following unspecified cerebrovascular

disease

SLP Component

Additional factors utilized to adjust case mix index calculationØ Mechanically Altered Diet

q Determined by K0510C2Ø Swallowing Disorder

q Determined by K0100Ø Cognitive Impairment

q Determined by C0500 or C1000

12 SLP Case-Mix Groups

Presence of Acute Neurologic Condition, SLP-Related

Comorbidity, or Cognitive Impairment

Mechanically Altered Diet or

Swallowing DisorderSLP Case Mix Group CMI

None Neither SA 0.68None Either SB 1.82None Both SC 2.66Any one Neither SD 1.46Any one Either SE 2.33Any one Both SF 2.97Any two Neither SG 2.04Any two Either SH 2.85Any two Both SI 3.51All three Neither SJ 2.98All three Either SK 3.69All three Both SL 4.19

Nursing Component

Ø Utilizes modified version of the RUG-IV Nursing Categoriesq Reduced to 25 PDPM RUGS from the original 43q Diagnosis codes are used to further classify

residents into one of the 25 PDPM RUG groups.Ø Nursing Function Score based on Section GG

Nursing Component

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

Nursing Component

Ø RUGs are grouped into six categories

q Extensive Services

q Special Care High

q Special Care Low

q Clinically Complex

q Behavioral Cognitive Symptoms

q Reduced Physical Function

Ø Three categories utilize diagnosis and coding

from section I of the MDS.

Nursing Component

Ø Special Care High Ø Diagnosis Coding in from Section I

q Septicemia (I2100)q Diabetes (I2900) with both of the following

§ (N0350A) Insulin injections all 7 days§ (N0350B) Insulin order changes on 2 or more

days

Nursing Component

Ø Special Care High Ø Diagnosis Coding in from Section I

q Quadriplegia (I5100) with§ Nursing Function Score greater than or equal to

eleven (11)q COPD (I6200) and

§ J1100C SOB when lying flat

Nursing Component

Ø 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 Component

Ø Special Care Lowq Diagnosis Coding

q Cerebral palsy (I4400) and§ Nursing Function Score of 11 or greater

q Multiple Sclerosis (I5200) and § Nursing Function Score of 11 or greater

q Parkinson's (I5300) and § Nursing Function Score of 11 or greater

q Respiratory Failure (I6300) and § Oxygen therapy while a resident (0100C2)

Nursing Component

Ø Clinically Complexq Diagnosis Coding

q Pneumonia (I2000) and§ Nursing Function Score of 11 or greater

Nursing Case Mix Groups

Non-Therapy Ancillary (NTA)ComponentØ Utilizes 50 diagnosis codes and extensive

services to identify additional comorbiditiesØ Must be coded on the UB04 or MDSØ Utilizes a points scale from 1 to 8 to calculate

comorbidity score

NTA Component

Ø The following conditions will be pulled from Section 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 Component

Ø The following conditions will be pulled from Section I – Active Conditions of the MDS.Ø I8000 – Additional Diagnoses

q Lung Transplant Statusq Major Organ Transplant Status, Except Lungq Opportunistic Infectionsq Bone, Joint, Muscle Infections/Necrosis, Except

Aseptic Necrosis of Boneq Chronic Myeloid Leukemiaq Endocarditis

NTA Component

Ø The following conditions will be pulled from Section I – Active Conditions of the MDS.Ø I8000 – Additional Diagnoses

q Immune Disordersq End-Stage Liver Diseaseq Narcolepsy and Cataplexyq Cystic Fibrosisq Specified Hereditary Metabolic and Immune

Disordersq Morbid Obesity

NTA Component

Ø The following conditions will be pulled from Section I – Active Conditions of the MDS.Ø I8000 – Additional Diagnoses

q Psoriatic Arthropathy and Systemic Sclerosisq Chronic Pancreatitisq Proliferative Diabetic Retinopathy and Vitreous

Hemorrhageq Complications of Specified Implanted Device or

Graftq Inflammatory Bowel Disease

NTA Component

Ø The following conditions will be pulled from Section I – Active Conditions of the MDS.Ø I8000 – Additional Diagnoses

q Aseptic Necrosis of Boneq Cardio-Respiratory Failure and Shockq Myelodysplastic Syndromes and Myelofibrosisq Systemic Lupus Erythematosus, Other

Connective Tissue Disorders, and Inflammatory Hemorrhage

q Severe Skin Burn or Condition

NTA Component

Ø The following conditions will be pulled from Section I – Active Conditions of the MDS.Ø I8000 – Additional Diagnoses

q Diabetic Retinopathy, Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

q Intractable Epilepsyq Disorders of Immunityq Cirrhosis of Liverq Respiratory Arrestq Pulmonary Fibrosis & Other Lung Disorders

NTA Component

Comorbidity Description ICD-10-CM Code ICD-10-CM Code Description

Endocarditis A0102 Typhoid fever with heart involvement

Endocarditis A1884 Tuberculosis of heart

Endocarditis A3282 Listerial endocarditis

Endocarditis A3951 Meningococcal endocarditis

Endocarditis A5203 Syphilitic endocarditis

Endocarditis A78 Q fever

Endocarditis B3321 Viral endocarditis

Endocarditis B376 Candidal endocarditis

Endocarditis I330 Acute and subacute infective endocarditis

Endocarditis I339 Acute and subacute endocarditis, unspecified

Endocarditis I38 Endocarditis, valve unspecified

Endocarditis I39 Endocarditis and heart valve disorders in diseases classified elsewhere

Endocarditis M3211 Endocarditis in systemic lupus erythematosus

NTA Component

Ø HIV/AIDS add-onØ Applied based on the presence of ICD-10-CM

code B20 on the SNF claim.

Ø Due to the significant increase in nursing cost to 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 3.259-11 NB 2.536-8 NC 1.853-5 ND 1.341-2 NE 0.960 NF 0.72

Coding Pitfalls and Tips

Principal Diagnosis

Ø 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”. Ø This definition has been expanded to include ALL

non-outpatient settings including SNFs / LTC facilities.

Principal Diagnosis43

Ø When a patient is treated for an acute condition in the hospital and transferred to a SNF for rehabq The acute condition, if still present is coded as the

first listed/principal diagnosis.q The aftercare is coded as the first listed/principal

diagnosis, if the acute condition is no longer present.

Principal Diagnosis44

Ø When a patient transitions to long term care or returns from hospital stay for continued long term careq The chronic condition, that requires continued stay

for long term care is the first listed/principal diagnosis.

q The acute condition or aftercare is sequenced as the first additional/secondary diagnosis.

Additional Diagnoses45

Ø Secondary/Additional Diagnoses – conditions that coexist at the time of admission, that develop subsequently during the resident’s stay or that affect the treatment the resident receives or the resident’s length of stay.q Diagnosis that support both the Principle Dx. This

is where you would include the therapy treatment diagnosis codes as they support the Admit Dx

Additional Diagnoses46

Ø Medicare Claims Processing Manual, Chapter Six, page 33, indicates the Principal Diagnosis and up to eight additional diagnosis codes are included in the claims review process.Ø This makes it imperative to get the most pertinent

diagnoses requiring skilled services in the top 8 boxes of this section.

Common Coding Errors47

Ø 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 criteria

per the Resident Assessment Instrument (RAI) Manual

Common Coding Errors48

Ø Coding Aftercare codes (Z codes) with injury or fracture codes with a 7th character that identifies the encounter type

Ø Incorrect 7th character selection for injury and fracture codes to identify the encounter type

Ø Coding conditions to a lower or higher level of specificity than provider documentation supports

Common Coding Errors49

Ø Coding acute condition, when conditions is resolved and skilled care is focused on the sequela or aftercare

Ø Coding symptoms with presence of a definitive diagnosis

Risks of Inaccurate Coding

Risks of Incorrect Coding51

Ø Inaccurate health recordØ Incomplete or inaccurate data on the MDSØ Incomplete or inaccurate data on the UB04

Inaccurate Health Record52

Ø Risk ManagementØ Diagnosis of osteoporosis in a resident that

obtains a fracture after rolling out of the bed in lowest position onto fall mats. q Coding guidelines indicate that the fracture may

be coded as a pathologic fracture.

Ø Quality CareØ Resident specific care based in part on their

specific diagnoses and other care needs.

Incomplete/Inaccurate MDS53

Ø Care PlanningØ Diagnoses aid in identification of problems and

determination of interventionsØ Quality Measures

Ø Percentage of Short Stay Residents with Pressure Ulcers that are New or Worseningq Includes Covariates related to diabetes or

peripheral vascular disease coded in Section I

Incomplete/Inaccurate UB54

Ø Claims Denials

Ø Remittance advice informs of invalid diagnosis, but does not specify which code or sequence

Ø Quality Measures

Ø SNF Readmission Measure (SNFRM)

q Exclusions include hospitalized for primary diagnosis related to medical (non-surgical)

treatment of cancer

Planning

What’s Next56

Ø Complete routine coding and MDS auditsØ Ensure staff have current ICD-10-CM code

booksØ Updated every October 1st

Ø Provide staff with basic ICD-10-CM trainingØ Provide staff with PDPM training

What’s Next57

Ø Ensure that all disciplines are utilizing the

same primary diagnosis

Ø Review diagnosis coding during Triple Check

(Pre-Bill) meeting

Ø Review code updates effective October 1st and

revise codes for current residents, as needed

Questions???

Q & A 58

You may also contact Robin A. Bleier, President with regard to this or other services at robin@rbhealthpartners.com or call us at 727.786.3032.

Thank you for your participation

To learn more about this topic please contact Heather Py, RHIT, CCS, CHPS, RAC-CT, Director of Health Information Management at heather@rbhealthpartners.com.

2018 © RB Health Partners, Inc.