Section II - Selection of Principal Diagnosis Applies to all inpatient care settings including LTC. (The principal diagnosis may or may not be the reason for Medicare skilled … Principal diagnosis is defined in Uniform Hospital Discharge Data Set (UHDDS) as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Go to the Skilled Nursing Facility Prospective Payment System booklet for more information. A. admission, primary, discharge, and; secondary. A discharge diagnosis should be selected when a resident is discharged to home, transferred to another facility, or at the time of death. The “first listed diagnosis” is the diagnosis which is chiefly responsible for the admission to, or continued residence in the nursing facility and should be sequenced first. Coding directives in the ICD-10 CM classification take precedence over all other guidelines. Fig. The primary diagnosis is also used to represent the reason for the resident’s continued stay in the facility after the admission diagnosis has been resolved. I am confused about how to identify the principle diagnosis in these cases, FTT or the UTI. There are four common diagnoses are. Review claims prior to billing in order to confirm the information, and ensure that supporting documentation, including daily skilled notes, are in the medical record. Selecting codes for your Skilled Nursing Facility (SNF) claims can often be mind-boggling. 550 Cochituate Road, Framingham, MA 01701 UHDDS definitions apply to all non-outpatient settings, including skilled nursing facilities (SNFs). The growing population of elderly patients and their higher share of overall health spending have made skilled nursing facilities (SNFs) an increasingly important part of the healthcare continuum. Medicare certifies LTCHs as acute care hospitals as part of its condition of participation in the Medicare program. But with 16,000 facilities in the United States and more and more hospitals participating in risk-based programs (accounting for over 10,000 episodes as of April 6, 2017), healthcare executives are becoming even more selective about the facilities they recommend. Inpatient rehab coders must use the most detailed HCC codes to reflect the correct coding conventions aligned with the patient’s current illness or injury, ongoing comorbidities, or any … A condition that started while you were getting care in the SNF for a hospital-related medical condition (for example, if you develop an infection that requires IV antibiotics while you're getting SNF care) Section II. Certain Z codes may only be used as first- listed or principal diagnosis in certain situations. Q: The majority of the admissions I am reviewing this week are for an elderly population. Enter present on admission (POA) indicator in the shaded area: Y=Yes 22x = SNF Inpatient (Medicare Part B Only) 23x = SNF Outpatient 28x = SNF Swing Bed ... outpatient claims and nursing facilities. These are also known as additional diagnoses. Skilled Nursing Facility requirements must be met to obtain benefits. Interestingly, the third most commonly reported ICD-10 code by SNFs is aftercare following joint replacement surgery (Z471). If a resident dies or is transferred to another facility, the discharge diagnosis would be considered the cause of death or the reason for transfer. In this case, the patient no longer has COVID-19 and the pneumothorax is a residual effect (sequelae). The second most commonly diagnosed ailment in SNFs is pneumonia (J189) with 122,039 … Data sources: Facility staffing, characteristics, and case-mix data were from the federal On-Line Survey Certification and Reporting (OSCAR) system and other data were from public sources. If longer-term care is needed, those costs will come out of … This means that a large amount of patients are receiving post-acute therapy at SNFs after their joint replacement surgeries, showing that SNFs are beneficial in the short-term (as well as the long-term) care of patients. The hospital’s final diagnosis will indicate the reason the resident was treated in the hospital. Let our experienced team perform a billing audit to help prevent the possibility of claim denials. Therefore, the term pri­mary diagnosis may conjure different definitions, depending on the individual. The second most commonly diagnosed ailment in SNFs is pneumonia (J189) with 122,039 total diagnoses. Billing Situations Among Other Facilities If a beneficiary needs a Skilled Nursing Facility and goes but doesn’t have a qualifying stay in a hospital facility, they can move to a Skilled Nursing Facility … As proposed, the new measure would use the principal diagnosis on Medicare hospital claims for skilled-nursing facility residents from the fourth day after skilled-nursing facility … Pneumonia is understood to be another regular and challenging problem in nursing facilities. The primary/principal diagnosis per the Uniform Hospital Discharge Data Set (UHDDS) defines it as a “condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”. ... an uncomplicated elective laparoscopic cholecystectomy without further explanation before being transferred to a SNF. 1 Is all of this confusing to you? Aims: To assess the prevalence, health care resource utilization (HCRU), and economic burden of disease among Medicare beneficiaries with a principal diagnosis of osteoarthritis (OA) of the knee. For some time now, UTIs have been reported as one of the most common long-term care facility infections. accounting for approximately 14 percent of all diagnoses; however, effective October 1, 2014, these diagnoses are no longer permitted as principal diagnosis codes on hospice claims. Section II: Selection of Principal Diagnosis directs us in selecting the PDx code. The IRF physicians and clinical support staff must document to prove medical necessity for treating the principal diagnosis on admission (POA), as well as the ongoing comorbidities. support@definitivehc.com, © 2020 Definitive Healthcare, LLC. Primary diagnosis codes are selected for the condition responsible for the resident’s admission to the facility. At times, there may be a conflict in the requirements and terminology. The Coding Clinic published for the fourth quarter of 2013 notes that patients admitted to skilled nursing homes’ rehabilitation unit should have the underlying reason for debility … Well, you’re not alone. For example, the term primary diagnosis is often used to indicate the reason for skilled Medicareservices, which may not be the same reason for the resident’s continued stay. Answer: Admission and principal diagnosis selection may depend on the resident’s status in the facility. Diagnosis codes can be assigned at the time of admission, concurrently as diagnosis arises, and at the time of discharge. Urinary tract infections (UTIs) (N390) are the number one most diagnosed ailment at SNFs with 135,950 diagnoses in total. It should not be used by individuals making medical decisions or selecting a facility. If a resident was discharged to home, the discharge diagnosis would be the same as the principal diagnosis. SNFs should assign aftercare codes or a condition code with a seventh digit indicating subsequent care. When selecting the admission diagnosis, this diagnosis should be for the condition that necessitated the resident’s admission to the facility and the reason the resident needs care. listed or principal diagnosis code in the inpatient setting, or secondary code, depending on the circumstances of the encounter. Here are some common diagnoses that are seen at rehab units in skilled nursing facilities: Congestive heart failure. Type II Diabetes Mellitus. Well, you’re not alone. (508) 720-4224 In Medicare's prospective payment system for skilled nursing facilities, which data set determines a resident's classification into a resource utilization group? Research shows that more than 20 percent of Medicare beneficiaries discharged from a hospital to a SNF will return to a hospital within 30 days, costing Medicare more than $4 billion per year. For example, when coding an admission to the facility, the “first listed diagnosis” is the condition chiefly responsible for the admission to the facility. LTCHs are for clinically complex patients who have multiple acute or chronic conditions that require extended medical and rehabilitative treatments. Residents are admitted to SNFs with varying length of stays and the admission reason is often different from the reason for continued stay. Diagnosis codes can be assigned at the time of admission, concurrently as diagnosis arises, and at the time of discharge. under a Medicare Part A covered SNF stay (ancillary, routine, and capital), except some separately-payable Part B services. It should be the main reason the resident was admitted to your facility for the short-term services. During the time of admission, information is collected on the resident, which should be related to the resident’s preceding hospital stay. While diagnostic coding in SNFs is not directly related to reimbursement, coding incorrectly may incite a medical review of claims. Reducing readmissions in skilled nursing facilities (SNFs) is a top priority for the Centers for Medicare & Medicaid Services (CMS). This website is intended for industry professionals interested in operational information. CMS expects the principal diagnosis on the SNF claim to match the primary diagnosis in item I0020B. The principal diagnosis (first-listed) is the reason for the continued stay (e.g., COPD) in the nursing facility. The process by which health care facilities and payers determine anticipated care needs by reviewing tyupes and/or categories of patients treated by a facility is called_____ analysis case mix Diagnosis-related groups are organized into mutually exclusive categories called______, which are loosely based on body systems While diagnostic coding in SNFs is not directly related to reimbursement, coding incorrectly may incite a medical review of claims. There are many different causes of pneumonia, but elderly patients in general are more prone to this illness. hbspt.cta._relativeUrls=true;hbspt.cta.load(2297384, '77724aaf-66d4-4f4d-b71c-065a95bb6ad3', {}); Source: “ICD-10 Essential for Long-Term Care Your Guide to Preparation and Implementation”, Karen L. Fabrizio, RHIA, CPRA, 2012 HCPro, Inc. 5925 Stevenson Ave.2nd Floor, Suite GHarrisburg, PA 17112Ph: 800-320-5401 Fx: 717-233-4633, Skilled Nursing Billing: Understanding Which Diagnosis Code to Use, By Often, nursing facilities confuse the various diagnosis codes. (Question #16 was deleted on August 5, 2020. SNFdata.com provides online data about more than 13,000 Skilled Nursing Facilities. In other words, list the reason for home healthcare as the principal diagnosis. Figure 6.2 - Medicare Skilled Nursing Facility (SNF) Utilization, by Type of Facility: Calendar Year 2010; Figure 6.3 - Trends in the Top Five Medicare Skilled Nursing Facility Principal Diagnoses, Based on Number of Admissions: Calendar Years 1998, 2003, and 2010 Here is a breakdown of the guidance in Section II. In any of these situations, a principal diagnosis may represent the admission diagnosis, the reason for continued stay, or discharge diagnosis. Further, UTIs, if untreated, can result in sepsis (A419) — a fatal ailment with an approximate 40 percent mortality rate — which we see as the fourth most common diagnosis as per this list. 1 Data from Definitive Healthcare’s Long-Term Care database (accessed June 2020). Annual Medicare Data is from the Centers for Medicare and Medicaid Services (CMS) Medicare Standard Analytical Files (SAF). It seems that they all have the same admitting diagnoses: Failure to thrive (FTT), urinary tract infection (UTI), fever, dehydration, altered mental status (AMS). The fourth type of diagnosis code is secondary diagnoses. Definitive's Healthcare Insights are developed with data from the Definitive Healthcare platform. It’s important to note that the hospital’s principal diagnosis may not be the reason long-term care is needed. Z codes may be used as either a first- listed or principal diagnosis code in the inpatient setting, or secondary code, depending on the circumstances of the encounter. sales@definitivehc.com NURSING Base Rate Nursing CMI Nursing TOTAL NON-CASE-MIX Base Rate TOTAL: 11 MLN Call: SNF PPS: Patient Driven Payment Model, 2018 Basics of PDPM Diagnoses will drive reimbursement Principal diagnosis Secondary diagnoses Major surgery in last 100 days Reduces number of MDS Assessments to 3: 5 Day Assessment Jennifer Matoushek, Senior Consultant. Objective: To examine the relationship between nursing staffing levels in U.S. nursing homes and state Medicaid reimbursement rates. This is unfortunate because UTIs are an avoidable infection that continue to plague SNFs. In any of these situations, a principal diagnosis may represent the admission diagnosis, the reason for continued stay, or discharge diagnosis. Is all of this confusing to you? Status-post TKA (total knee arthroplasty) Status-post THA (total hip arthroplasty) Debility . Codes from chapter 18 are not to be assigned as principal when a related, definitive diagnosis has been established. The most recent annual Medicare data is from calendar year 2018; 2019 data is scheduled to be released in Fall 2020. There are currently 67.7 million Medicare beneficiaries in the U.S. All Rights Reserved. |, Top 50 Skilled Nursing Facilities Diagnoses, Urinary tract infection, site not specified, Aftercare following joint replacement surgery, Chronic obstructive pulmonary disease with (acute) exacerbation, Chronic obstructive pulmonary disease, unspecified, Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, Acute on chronic diastolic (congestive) heart failure, Encounter for surgical aftercare following surgery on the digestive system, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Non-ST elevation (NSTEMI) myocardial infarction, Encounter for orthopedic aftercare following surgical amputation, Encounter for surgical aftercare following surgery on the circulatory system, Pneumonitis due to inhalation of food and vomit, Acute and chronic respiratory failure with hypoxia, Atherosclerotic heart disease of native coronary artery without angina pectoris, Unspecified dementia without behavioral disturbance, Acute on chronic systolic (congestive) heart failure, Acute respiratory failure, unspecified whether with hypoxia or hypercapnia, Enterocolitis due to Clostridium difficile, not specified as recurrent, Type 2 diabetes mellitus without complications, Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, The second most commonly diagnosed ailment in SNFs is, Interestingly, the third most commonly reported ICD-10 code by SNFs is. MDS T/F: In an LTCH facility, coders should code the diagnosis that the patient was treated for in the acute care hospital. Selecting the correct diagnosis code is essential to capturing the clinical condition of residents, [Blog Series] Making Sense of Medical Necessity for Therapy: Week 2. Principal Diagnosis (PDX): The circumstances of inpatient admission always govern the selection of the principal diagnosis. Wound Infection Z codes are not procedure codes. Certain Z codes may only be used as first- listed or principal diagnosis in certain situations. Refer to Official Coding Guidelines for details. In order for a facility to qualify as an LTCH under Medicare, the average length of stay of a patient must be greater than 25 days, unless the facility qualifies under section 1886(d) of the Social Security Act. Materials and methods: Patients with a principal diagnosis of knee OA were identified from the 5% noninstitutional sample file within 2009 and 2014 Medicare fee-for-service Limited Data Sets. For a short-term resident, admitted for skilled services, the admission and principal diagnosis may be the same. the principal diagnosis from first hospice claim, whether skilled nursing facility (SNF) episode occurred prior to hospice admission, distance between SNF episode and hospice admission, and Medicare inpatient, SNF and home health care expenditures 180 days prior to hospice admission. Diagnosis codes used to capture external causes of accidental injuries—codes beginning with the letter W—being used as principal codes versus the reason for SNF care diagnosis Capturing diagnosis codes on claim forms that haven’t been updated or sequenced to reflect the current condition (s) for why the skilled services are being provided: Want even more insights? These diagnoses should be for all conditions that coexist at the time of admission, develop during the resident’s stay, or affect the treatment the resident receives. Start a Free Trial now and get access to the highest quality data and intelligence on hospitals, physicians, and other healthcare providers. On the other hand, if a patient is admitted with sepsis due to COVID-19 pneumonia and the sepsis meets the definition of principal diagnosis, then the code for viral sepsis (A41.89) should be assigned as principal diagnosis followed by codes U07.1 and J12.89, as secondary diagnoses. Medicare will pay for short-term skilled nursing facility stays when medically necessary. SNFs provide essential care to elderly patients and, more specifically, Medicare beneficiaries. The Skilled Nursing Facility (SNF) Healthcare-Associated Infections (HAIs) Requiring Hospitalizations measure would track the rate of nursing home stays that result in acquired infections — specifically by tracking the principal diagnosis on each nursing home resident’s Medicare hospital claims during a window that stretches from the fourth day of the SNF stay to the third day after a nursing … Medicare exempts CAH swing bed services from the SNF PPS and pays them based on 101 percent of the reasonable cost of the services. Complete calendar year data is projected to be released each fall by the CMS. Status-post CVA (cerebrovascular accident) Status-post MI (myocardial infarction) Urinary Tract Infection. Assign code J93.83, Other pneumothorax, as the principal diagnosis, followed by code B94.8, Sequelae of other specified infectious and parasitic diseases. Codes for Symptoms, Signs, and Ill-defined Conditions. 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