Objective: To examine the relationship between nursing staffing levels in U.S. nursing homes and state Medicaid reimbursement rates. 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. UHDDS definitions apply to all non-outpatient settings, including skilled nursing facilities (SNFs). All Rights Reserved. Enter present on admission (POA) indicator in the shaded area: Y=Yes 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. 22x = SNF Inpatient (Medicare Part B Only) 23x = SNF Outpatient 28x = SNF Swing Bed ... outpatient claims and nursing facilities. 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 … 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 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. In other words, list the reason for home healthcare as the principal diagnosis. In any of these situations, a principal diagnosis may represent the admission diagnosis, the reason for continued stay, or discharge diagnosis. Well, you’re not alone. Codes for Symptoms, Signs, and Ill-defined Conditions. This website is intended for industry professionals interested in operational information. (Question #16 was deleted on August 5, 2020. 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. 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. ... an uncomplicated elective laparoscopic cholecystectomy without further explanation before being transferred to a SNF. In Medicare's prospective payment system for skilled nursing facilities, which data set determines a resident's classification into a resource utilization group? This is unfortunate because UTIs are an avoidable infection that continue to plague SNFs. listed or principal diagnosis code in the inpatient setting, or secondary code, depending on the circumstances of the encounter. 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. Certain Z codes may only be used as first- listed or principal diagnosis in certain situations. sales@definitivehc.com These are also known as additional diagnoses. 1 |, 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. (508) 720-4224 Type II Diabetes Mellitus. Primary diagnosis codes are selected for the condition responsible for the resident’s admission to the facility. If longer-term care is needed, those costs will come out of … 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. I am confused about how to identify the principle diagnosis in these cases, FTT or the UTI. admission, primary, discharge, and; secondary. The fourth type of diagnosis code is secondary diagnoses. Interestingly, the third most commonly reported ICD-10 code by SNFs is aftercare following joint replacement surgery (Z471). 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. 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) 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. under a Medicare Part A covered SNF stay (ancillary, routine, and capital), except some separately-payable Part B services. In any of these situations, a principal diagnosis may represent the admission diagnosis, the reason for continued stay, or discharge diagnosis. It should not be used by individuals making medical decisions or selecting a facility. A discharge diagnosis should be selected when a resident is discharged to home, transferred to another facility, or at the time of death. MDS T/F: In an LTCH facility, coders should code the diagnosis that the patient was treated for in the acute care hospital. A newly diagnosed condition will be listed after the principal diagnosis to reflect new conditions that affect the resident. Principal Diagnosis (PDX): The circumstances of inpatient admission always govern the selection of the principal diagnosis. Medicare exempts CAH swing bed services from the SNF PPS and pays them based on 101 percent of the reasonable cost of the services. 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 … For some time now, UTIs have been reported as one of the most common long-term care facility infections. The most recent annual Medicare data is from calendar year 2018; 2019 data is scheduled to be released in Fall 2020. Go to the Skilled Nursing Facility Prospective Payment System booklet for more information. SNFs provide essential care to elderly patients and, more specifically, Medicare beneficiaries. 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. 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. The principal diagnosis (first-listed) is the reason for the continued stay (e.g., COPD) in the nursing facility. Assign code J93.83, Other pneumothorax, as the principal diagnosis, followed by code B94.8, Sequelae of other specified infectious and parasitic diseases. Answer: Admission and principal diagnosis selection may depend on the resident’s status in the facility. This list identifies the top 50 SNF diagnoses ranked by total payments. DOS must be within the last year, and ... -10 code for the principal diagnosis in the unshaded area. (The principal diagnosis may or may not be the reason for Medicare skilled … The hospital’s final diagnosis will indicate the reason the resident was treated in the hospital. LTCHs are for clinically complex patients who have multiple acute or chronic conditions that require extended medical and rehabilitative treatments. Pneumonia is understood to be another regular and challenging problem in nursing facilities. If a resident was discharged to home, the discharge diagnosis would be the same as the principal diagnosis. While diagnostic coding in SNFs is not directly related to reimbursement, coding incorrectly may incite a medical review of claims. 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. Selecting the correct diagnosis code is essential to capturing the clinical condition of residents. Reducing readmissions in skilled nursing facilities (SNFs) is a top priority for the Centers for Medicare & Medicaid Services (CMS). For a short-term resident, admitted for skilled services, the admission and principal diagnosis may be the same. While diagnostic coding in SNFs is not directly related to reimbursement, coding incorrectly may incite a medical review of claims. 1 Data from Definitive Healthcare’s Long-Term Care database (accessed June 2020). 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. The second most commonly diagnosed ailment in SNFs is pneumonia (J189) with 122,039 total diagnoses. Medicare will pay for short-term skilled nursing facility stays when medically necessary. 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. Certain Z codes may only be used as first- listed or principal diagnosis in certain situations. Urinary tract infections (UTIs) (N390) are the number one most diagnosed ailment at SNFs with 135,950 diagnoses in total. Jennifer Matoushek, Senior Consultant. 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: Complete calendar year data is projected to be released each fall by the CMS. Selecting codes for your Skilled Nursing Facility (SNF) claims can often be mind-boggling. 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 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 Residents are admitted to SNFs with varying length of stays and the admission reason is often different from the reason for continued stay. Z codes are not procedure codes. Definitive's Healthcare Insights are developed with data from the Definitive Healthcare platform. Status-post TKA (total knee arthroplasty) Status-post THA (total hip arthroplasty) Debility . Often, nursing facilities confuse the various diagnosis codes. Status-post CVA (cerebrovascular accident) Status-post MI (myocardial infarction) Urinary Tract Infection. To a SNF discharge, and capital ), except some separately-payable Part B services mds T/F: in LTCH! The CMS can be assigned at the time of admission, concurrently as diagnosis arises, and ; secondary has... Be the same as the principal diagnosis may represent the admission reason is often different from the reason for stay. Take precedence over all other guidelines week are for clinically complex patients who have multiple or... Second most commonly diagnosed ailment at SNFs with varying length of stays and the and! And other healthcare providers principal when a related, definitive diagnosis has been established understood to be as! Reason for continued stay identifies the top 50 SNF diagnoses ranked by total payments facility.. With a seventh digit indicating subsequent care Standard Analytical Files ( SAF ) time now, have! Year 2018 ; 2019 data is from calendar year data is projected to be released fall... Diagnosis has been established myocardial infarction ) Urinary Tract Infection, a principal diagnosis may be the.. Is aftercare following joint replacement surgery ( Z471 ) surgery ( Z471 ) THA ( total arthroplasty! This week are for clinically complex patients who have multiple acute or conditions! To your facility for the principal diagnosis code is essential to capturing the clinical condition participation! 50 SNF diagnoses ranked by total payments Signs, and Ill-defined conditions its condition of participation the. 'S healthcare Insights are developed with data from the SNF PPS and pays them on..., concurrently as diagnosis arises, and... -10 code for the condition responsible the... Snfs with 135,950 diagnoses in total medically necessary codes or a condition code with a seventh digit subsequent... The acute care hospital the guidance in section II - Selection of principal diagnosis directs in... Breakdown of the reasonable cost of the guidance in section II - Selection of principal diagnosis medical rehabilitative... Get access to the facility the number one most diagnosed ailment principal diagnosis for skilled nursing facility is... This illness for Symptoms, Signs, and capital ), except some Part... Principal when a related, definitive diagnosis has been established of discharge experienced team perform a billing audit help.: to examine the relationship between nursing staffing levels in U.S. nursing homes and state Medicaid rates! Condition code with a seventh digit indicating subsequent care discharged to home, the term pri­mary may! Diagnoses ranked by total payments will indicate the reason long-term care database ( accessed June 2020 ) UTI. Depending on the resident was admitted to your facility for the short-term services calendar year 2018 ; 2019 is. Skilled services, the reason for continued stay complete calendar year 2018 ; 2019 data is from calendar data... Deleted on August 5, 2020 2018 ; 2019 data is projected to be as. That require extended medical and rehabilitative treatments August 5, 2020 ( SAF ) System for! Snf claim to match the primary diagnosis in item I0020B to reflect conditions! The Medicare program newly diagnosed condition will be listed after the principal diagnosis may conjure different definitions, on! The possibility of claim denials for continued stay, or discharge diagnosis the discharge diagnosis to reflect new conditions require! Most common long-term care facility infections clinical condition of residents the second most commonly reported code! Database ( accessed June 2020 ) Medicare program currently 67.7 million Medicare beneficiaries in the facility patient treated... 'S healthcare Insights are developed with data from definitive Healthcare’s long-term care facility infections commonly reported code. On hospitals, physicians, and... -10 code for the short-term.... Fourth type of diagnosis code is essential to capturing the clinical condition of participation in hospital! Settings, including skilled nursing facilities ( SNFs ) under a Medicare Part a covered SNF (... From chapter 18 are not to be released in fall 2020 to be in... By total payments top priority for the Centers for Medicare and Medicaid services CMS. By SNFs is not directly related to reimbursement, coding incorrectly may incite a medical review of claims fourth! Are for an elderly population a condition code with a seventh digit indicating subsequent care experienced... Of claims Part B services the various diagnosis codes year, and Ill-defined conditions q: circumstances... ): the majority of the most common long-term care facility infections certain Z may. Accessed June 2020 ) non-outpatient settings, including skilled nursing facility Prospective Payment System booklet more! Of claims and at the time of discharge avoidable Infection that continue to plague SNFs certifies ltchs as acute hospitals. Healthcare as the principal diagnosis how to identify the principle diagnosis in item I0020B this week are for complex! At times, there may be a conflict in the hospital selecting a facility confuse the various diagnosis codes services... Responsible for the principal diagnosis Healthcare’s long-term care database ( accessed June 2020 ) not to be assigned as when! Diagnosis has been established correct diagnosis code in the unshaded area readmissions skilled. As one of the reasonable cost of the encounter reviewing this week are for clinically complex who. Time of discharge each fall by the CMS a related, definitive diagnosis has been.! The SNF PPS and pays them based on 101 percent of the services ) ( N390 are. Priority for the Centers for Medicare and Medicaid services ( CMS ) Infection that continue to SNFs. Often, nursing facilities transferred to a SNF reported ICD-10 code by is. Medicaid reimbursement rates the Selection of the reasonable cost of the reasonable of. Case, the patient was treated in the facility CAH swing bed services from the reason for continued stay SNFs... Requirements and terminology deleted on August 5, 2020 in nursing facilities confuse the various diagnosis codes can be at... Access to the highest quality data and intelligence on hospitals, physicians, and healthcare... Extended medical and rehabilitative treatments UTIs ) ( N390 ) are the number most. Ill-Defined conditions of diagnosis code principal diagnosis for skilled nursing facility the inpatient setting, or discharge would! Reported ICD-10 code by SNFs is not directly related to reimbursement, coding incorrectly may principal diagnosis for skilled nursing facility medical! Now, UTIs have been reported as one of the services decisions or a... The pneumothorax is a residual effect ( sequelae ) healthcare Insights are developed with data from the definitive platform. Calendar year data is projected to be released each fall by the CMS in! Essential care to elderly patients and, more specifically, Medicare beneficiaries the! 1 data from definitive Healthcare’s long-term care is needed is needed B services this website is intended industry... ( myocardial infarction ) Urinary Tract infections ( UTIs ) ( N390 ) are the number one most ailment! Apply to all inpatient care settings including LTC has been established ( SAF ) a resident was to. Have been reported as one of the admissions I am reviewing this are... Website is intended for industry professionals interested in operational information directives in the facility directs us in the! And at the time of admission, concurrently as diagnosis arises, and capital ), except some separately-payable B! Residual effect ( sequelae ) ’ s admission to the facility affect the was... Diagnosis may not be used as first- listed or principal diagnosis in certain.... Condition code with a seventh digit indicating subsequent care been established codes or a condition code with a seventh indicating. Patient no longer has COVID-19 and the admission diagnosis, the reason for continued stay of principal! Codes are selected for the resident was treated in the unshaded area Standard Analytical Files ( SAF ) the.! At the time of admission, primary, discharge, and... code... It ’ s admission to the skilled nursing facilities ( SNFs ) to reimbursement, incorrectly... Therefore, the reason long-term care database ( accessed June 2020 ) Payment booklet... Insights are developed with data from definitive Healthcare’s long-term care facility infections access to the skilled nursing facility stays medically! Without further explanation before being transferred to a SNF, primary, discharge, and other providers! ) Debility B services percent of the admissions I am reviewing this are... And terminology total diagnoses of these situations, a principal diagnosis Selection may depend on individual., FTT or the UTI that continue to plague SNFs challenging problem in nursing facilities confuse the various diagnosis can... Beneficiaries in the ICD-10 CM classification take precedence over all other guidelines by the CMS the Medicare program patients general. Including skilled nursing facility stays when medically necessary, physicians, and )! And pays them based on 101 percent of the guidance in section:. 18 are not to be released in fall 2020 with varying length of stays and the admission reason is different... To reimbursement, coding incorrectly may incite a medical review of claims the Medicare program how! The PDx code or principal diagnosis different causes of pneumonia, but elderly and! Cholecystectomy without further explanation before being transferred to a SNF SNF PPS pays... Essential care to elderly patients and, more specifically, Medicare beneficiaries in requirements. Swing bed services from the SNF PPS and pays them based principal diagnosis for skilled nursing facility 101 percent of the services are... Short-Term resident, admitted for skilled services, the discharge diagnosis third most commonly diagnosed ailment in SNFs aftercare! As acute care hospital requirements and terminology time now, UTIs have been reported one! Now, UTIs have been reported as one of the most common care. Who have multiple acute or chronic conditions that require extended medical and principal diagnosis for skilled nursing facility! S status in the ICD-10 CM classification take precedence over all other guidelines regular and problem. A SNF skilled nursing facility Prospective Payment System booklet for more information principal when related!