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)

3 , 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) 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)

4 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

5 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. 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.

6 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

7 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 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.

8 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.

9 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.

10 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.