REIMBURSEMENT AND ICD-10 CODING

1 REIMBURSEMENTAND ICD-10 CODINGD ecember 2018 -RB Health Partners, Participants will learn The role of diagnosis CODING in the Patient Driven Payment Model (PDPM). The importance of correct diagnosis identification and CODING The impact of diagnosis CODING on the revenue cycle How to prepare for increased importance of diagnosis CODING with the implementation of PDPMD iagnoses and PDPMP atient-Driven Payment Model (PDPM) OverviewPDPM uses clinical conditions to determine the resident s payment category, rather than the amount of therapy provided. PDPM OverviewPDPM is composed of five case mix adjusted payment components and one non-case mix component: qPhysical Therapy (PT) qOccupational Therapy (OT) qSpeech Language Pathology (SLP) qNursing qNon-Therapy Ancillaries Services (NTA)qNon-Case Mix ComponentPDPM Overview All residents will be classified into PT, OT, and SLP categories regardless of whether they are on therapy case and OT Components PT and OT Case Mix are calculated in the same manner, but paid separately based on separate case-mix indices.

2 Drivers of PT and OT componentqPrimary reason for skilled stay Utilizes diagnosis codes to classify residents into on of four PT and OT clinical categories qFunction ScorePT and OT ComponentsSelecting of the primary reason for skilled stay: qDetermine resident s primary diagnosis This code, or codes, must be entered into MDS Item the primary diagnosis identify one of the four clinical categories. Major joint replacement or spinal surgery Other orthopedic Non-orthopedic surgery Medical ManagementPT and OT ComponentsSelecting of the primary reason for skilled stay: qSome codes may map to more than one clinical category qFurther 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 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)

3 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 prosthesisZ471 Aftercare following joint replacement surgeryPT and OT ComponentsPT and OT Clinical Category Primary diagnosis Clinical CategoryMajor joint Replacement or Spinal Surgery Major joint Replacement Spinal SurgeryOther Orthopedic Orthopedic Surgery (Except Major joint Replacement or Spinal Surgery) Non-Surgical Orthopedic/MusculoskeletalPT and OT Clinical CategoriesPT and OT Clinical Category Primary diagnosis Clinical CategoryNon-Orthopedic Surgery and Acute Neurologic Non-Orthopedic Surgery Acute Neurologic Medical Management Acute Infections Cardiovascular and Coagulations Pulmonary Cancer Medical Management16 PT and OT Case-Mix GroupsClinical CategoryFunction ScorePT Case Mix GroupCMIM ajor joint Replacement or Spinal joint Replacement or Spinal joint Replacement or Spinal joint Replacement or Spinal Surgery and Acute Surgery and Acute Surgery and Acute Surgery and Acute Component ST Case Mix utilizes diagnosis codes to classify residents into neurologic or non-neurologic clinical category qIt also utilizes diagnosis CODING to capture SLP related comorbidities.

4 Oral Cancers Speech Language DeficitsSLP Component Five Characteristics that will impact the SLP ComponentqAcute Neurologic or Non-NeurologicqSLP-Related ComorbidityqCognitive ImpairmentqMechanically Altered DietqSwallowing DisorderSLP ComponentThe following comorbidities will be pulled from Section I Active Conditions of the MDS Item I4300. Aphasia Item I4500. CVA, TIA, Stroke Item I4900. Hemiplegia or Hemiparesis Item I5500. Traumatic Brain InjurySLP ComponentThe following comorbidities will be pulled from Section I Active Conditions of the MDS Item I8000. qLaryngeal CancerqApraxiaqDysphagiaqALSqOral CancersqSpeech and Language DeficitsSLP ComponentConditionICD-10-CM CodeDescriptionSpeech and Language speech and language deficits following unspecified cerebrovascular diseaseSpeech and Language following unspecified cerebrovascular diseaseSpeech and Language following unspecified cerebrovascular diseaseSpeech and Language following unspecified cerebrovascular diseaseSpeech and Language disorder following unspecified cerebrovascular diseaseSpeech and Language speech and language deficits following unspecified cerebrovascular diseaseSLP ComponentAdditional factors utilized to adjust case mix index calculation Mechanically Altered DietqDetermined by K0510C2 Swallowing DisorderqDetermined by K0100 Cognitive ImpairmentqDetermined by C0500 or C100012 SLP Case-Mix GroupsPresence

5 Of Acute Neurologic Condition, SLP-Related Comorbidity, or Cognitive ImpairmentMechanically Altered Diet or Swallowing DisorderSLP Case Mix Component Utilizes modified version of the RUG-IV Nursing CategoriesqReduced to 25 PDPM RUGS from the original 43qDiagnosis codes are used to further classify residents into one of the 25 PDPM RUG groups. Nursing Function Score based on Section GGNursing Component Further division is based on the presence of the following conditions or services:qTracheostomy and Ventilator/RespiratorqInfection IsolationqDepressionqRestorative Nursing ServicesNursing Component RUGs are grouped into six categoriesqExtensive ServicesqSpecial Care HighqSpecial Care LowqClinically ComplexqBehavioral Cognitive SymptomsqReduced Physical Function Three categories utilize diagnosis and CODING from section I of the Component Special Care High diagnosis CODING in from Section IqSepticemia (I2100)qDiabetes (I2900) with both of the following (N0350A) Insulin injections all 7 days (N0350B) Insulin order changes on 2 or more daysNursing Component Special Care High diagnosis CODING in from Section IqQuadriplegia (I5100) with Nursing Function Score greater than or equal to eleven (11)qCOPD (I6200) and J1100C SOB when lying flatNursing Component Special Care HighqFever (J1550A) and one of the following.

6 QPneumonia (I2000)qVomiting (J1550B)qWeight Loss (K0300, 1 or 2)qFeeding Tube (K0510B1 or K0510B2) Nursing Component Special Care LowqDiagnosis CodingqCerebral palsy (I4400) and Nursing Function Score of 11 or greaterqMultiple Sclerosis (I5200) and Nursing Function Score of 11 or greaterqParkinson's (I5300) and Nursing Function Score of 11 or greaterqRespiratory Failure (I6300) and Oxygen therapy while a resident (0100C2)Nursing Component Clinically ComplexqDiagnosis CodingqPneumonia (I2000) and Nursing Function Score of 11 or greaterNursing Case Mix GroupsNon-Therapy Ancillary (NTA)Component Utilizes 50 diagnosis codes and extensive services to identify additional comorbidities Must be coded on the UB04 or MDS Utilizes a points scale from 1 to 8 to calculate comorbidity scoreNTA Component The following conditions will be pulled from Section I Active Conditions of the MDS.

7 Multiple Sclerosis (I5200) Asthma, COPD, Chronic Lung Disease (I6200) Wound Infections (I2500) Diabetes Mellitus (DM) (I2900) Multi-Drug Resistant Organism (MDRO) (I1700) Malnutrition (I5600)NTA Component The following conditions will be pulled from Section I Active Conditions of the MDS. I8000 Additional DiagnosesqLung Transplant StatusqMajor Organ Transplant Status, Except LungqOpportunistic InfectionsqBone, joint , Muscle Infections/Necrosis, Except Aseptic Necrosis of BoneqChronic Myeloid LeukemiaqEndocarditisNTA Component The following conditions will be pulled from Section I Active Conditions of the MDS. I8000 Additional DiagnosesqImmune DisordersqEnd-Stage Liver DiseaseqNarcolepsy and CataplexyqCystic FibrosisqSpecified Hereditary Metabolic and Immune DisordersqMorbid ObesityNTA Component The following conditions will be pulled from Section I Active Conditions of the MDS.

8 I8000 Additional DiagnosesqPsoriatic Arthropathy and Systemic SclerosisqChronic PancreatitisqProliferative Diabetic Retinopathy and Vitreous HemorrhageqComplications of Specified Implanted Device or GraftqInflammatory Bowel DiseaseNTA Component The following conditions will be pulled from Section I Active Conditions of the MDS. I8000 Additional DiagnosesqAseptic Necrosis of BoneqCardio-Respiratory Failure and ShockqMyelodysplastic Syndromes and MyelofibrosisqSystemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory HemorrhageqSevere Skin Burn or ConditionNTA Component The following conditions will be pulled from Section I Active Conditions of the MDS. I8000 Additional DiagnosesqDiabetic Retinopathy, Except Proliferative Diabetic Retinopathy and Vitreous HemorrhageqIntractable EpilepsyqDisorders of ImmunityqCirrhosis of LiverqRespiratory ArrestqPulmonary Fibrosis & Other Lung DisordersNTA ComponentComorbidity DescriptionICD-10-CM CodeICD-10-CM Code DescriptionEndocarditis 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.

9 Valve unspecified Endocarditis I39 Endocarditis and heart valve disorders in diseases classified elsewhere Endocarditis M3211 Endocarditis in systemic lupus erythematosus NTA Component HIV/AIDS add-on Applied based on the presence of ICD-10 -CM code B20 on the SNF claim. Due to the significant increase in nursing cost to care for HIV/AIDS patients, the facility will get an 18% increase in NTA Case Mix GroupsNTA Comorbidity ScoreNTA Case Mix GroupCMI12+ Pitfalls and TipsPrincipal 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 . This definition has been expanded to include ALL non-outpatient settings including SNFs / LTC Diagnosis43 When a patient is treated for an acute condition in the hospital and transferred to a SNF for rehabqThe acute condition, if still presentis coded as the first listed/principal aftercareis coded as the first listed/principal diagnosis , if the acute condition is no longer Diagnosis44 When a patient transitions to long term care or returns from hospital stay for continued long term careqThe chronic condition, that requires continued stay for long term care is the first listed/principal acute condition or aftercareis sequenced as the first additional/secondary Diagnoses45 Secondary/Additional Diagnoses conditions that coexist at the time of admission.

10 That develop subsequently during the resident s stay or that affect the treatment the resident receives or the resident s length of that support both the Principle Dx. This is where you would include the therapy treatment diagnosis codes as they support the Admit DxAdditional Diagnoses46 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. This makes it imperative to get the most pertinent diagnoses requiring skilled services in the top 8 boxes of this CODING Errors47 Incorrect selection of principal diagnosis CODING and Sequencing of Hypertension (HTN) with Chronic kidney disease (CKD) CODING External Causes (V00-Y99) CODING UTI without meeting all of the criteria per the Resident Assessment Instrument (RAI) ManualCommon CODING Errors48 CODING Aftercare codes (Z codes)