ICD-10-CM AND THE PDPM

1 ICD-10-CM AND THE PDPMMary Ann P. Leonard, RHIA, RAC-CTHealth Information AND THE PDPMOBJECTIVES 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 codesHealth Information Professionals2 ICD-10-CM AND THE PDPMICD-10-CM SOURCEH ealth Information Professionals3 ICD-10-CM AND THE PDPMW here 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 completedHealth Information Professionals4 ICD-10-CM AND THE PDPMS ources 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 sourcesHealth Information Professionals5 ICD-10-CM AND THE PDPMWhat was the impact of ICD-10-CM in the past?

2 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, hemiplegia, Diabetes Mellitus or incorporated in other section of the MDS Section O for trach/vent care Under PDPM there is a direct relationship between the code assignment and payment categoriesHealth Information Professionals6 ICD-10-CM AND THE PDPMF actors 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 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 PROCEDUREE very facility should have a policy/procedure on diagnostic code 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 RAI COORDINATOR)Coding diagnoses in Section I is notbased on ICD codes.

3 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 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 WITH ICD-10-CM AND THE MDSC oding 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.

4 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 CoordinatorICD-10-CM AND THE PDPMSome 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 ( UTI, Pneumonia, Sepsis, etc.)

5 Long term residents who return after a hospital admission must be coded to the reason why they are long term ( '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 7thcharacter to identify the episode of care still applies A initial(acute)episodeofcare (diagnostic) D subsequent episode of care (treatment) S sequelaepisodeofcare(residual from previous injury or trauma StrokerelatedcodesareI69notI63, Information Professionals12 ICD-10-CM AND THE PDPMSome 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, transplant, morbid obesity, MS, CP, COPD, DM, etc.)

6 The ICD-10-CM code mustappear in I8000, if not a check-off, in order to receive the designated point/sHealth Information Professionals13 ICD-10-CM AND THE PDPMSome diagnostic codes which are Return to Provider when primary(under a recent vendor study Return to Provider codes were @ 10% of the primary diagnoses) Muscle weakness Personal History of pneumonia Encounter for other specified aftercare Encounter for other specified surgical aftercare Nondisplaced transverse fracture of shaft ofunspecifiedfibula, routine healing Adult failure to thrive WeaknessHealth Information Professionals14 ICD-10-CM AND THE PDPMSome diagnostic codes which are Return to Provider when primary functional quadriplegia Malaise R54 Age related debility Altered mental status Age related cognitive decline Repeated falls Unspecified lack of coordinationHealth Information Professionals15 ICD-10-CM AND THE PDPMSome diagnostic codes which are Return to Provider when primary Unspecified abnormalities of gait (all phases)

7 Other paralytic syndrome following cerebralinfarction affecting unspecifiedside Hemiplegia and hemiparesis following cerebralinfarction affecting unspecifiedside Gastrointestinal hemorrhage, unspecifiedHealth Information Professionals16 ICD-10-CM AND THE PDPMSome diagnostic codes which are Medical Management or Acute Neurologic when primary gait (Nonsurgicalorthopedic/Musculoskeltal) , unspecified Information Professionals17 ICD-10-CM AND THE PDPMSome diagnostic codes which are Medical Management or Acute Neurologic when primary symptoms and signs involving the nervous system andsignsinvolvingthemusculoskeletalsyste m vegetative state neglect syndrome deficitHealth Information Professionals18 ICD-10-CM AND THE PDPMSome diagnostic codes which are Medical Management or Acute Neurologic when primary speech disturbances (malignant) related fatigueHealth Information Professionals19 ICD-10-CM AND THE PDPMFive mistakes often made selecting ICD-10-CM codes in the SNF Using unspecified codes Coding resolved diagnoses Incorrect 7thcharacter Coding from the internet, a cheat sheet or facility software Coding a diagnosis that was not documented by a ProviderSOURCE.

8 Jessie McGill, AANAC newsletterHealth Information Professionals20 ICD-10-CM AND THE PDPMO ther mistakes often made selecting ICD-10-CM codes in the SNF Using multiple single codes when a one a combination code , will do (acute on chronic codes) 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 aftercareHealth 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? Associated problems? Pneumonia (cause? Type?) DM (Type 1? Type2? Any related conditions eg.))

9 Retinopathy, vascular related conditions? Skin related conditions?)Health Information Professionals22 ICD-10-CM AND THE PDPMOVERVIEW OF THEPDPM STRUCTUREH ealth Information Professionals23 ICD-10-CM AND THE PDPMH ealth Information Professionals24 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/categoryHealth Information Professionals25 ICD-10-CM AND THE PDPMICD-10-CM AND THE PDPMPT/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.

10 The CMI weight factor and daily payment rate are different for PT and OT After the 20thday, daily rate decreases by 2% every 7 daysHealth Information Professionals26 Health Information Professionals27 ICD-10-CM AND THE PDPMH ealth Information Professionals28 IDENTIFY ICD-10-CM CODEIDENTIFY FINAL CLINICAL CATEGORYIDENTIFY RESIDENT FUNCTION SCOREDETERMINE PDPM CMIPT/OT under PDPMICD-10-CM AND THE PDPMST 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 stayHealth Information Professionals29 ICD-10-CM AND THE PDPMH ealth Information Professionals30 ICD-10-CM AND THE PDPMH ealth Information Professionals31 IDENTIFY ICD-10-CM CODEIDENTIFY FINAL CLINICAL CATEGORYIDENTIFY COGNITIVE FUNCTION AND COMORBIDITIESSWALLOWING DISORDER OR MECHANICAL ALTERED DIET?