Are your SNF Coders Ready for PDPM?
I am sure you were all relieved when CMS granted a 30-day grace period before commencing with the new Patient Driven Payment Model (PDPM) in the SNF and Long Term Care settings. But that grace period is coming to an end in 3 weeks, after which time some 34,877 codes will be on the Return to Provider (RTP) list which was generated by CMS. This means that claims with these RTP codes assigned as the first listed code on the MDS Assessment, Section 10020B, are identified as “unable to process” and the claim is returned to the provider for correction and resubmission. This delays payment considerably, which has long range ramifications on your cash flow.
CMS has also issued the Accepted Codes list which includes 72,176 codes that map from MDS Section 10020B to the PDPM Clinical Categories. The SNF coders must be familiar with the CMS lists of RTP vs. Accepted Codes in order to achieve coding accuracy on long term care records. The full lists and additional information can be found at CMS website: https://www.cms.gov/medicare/medicare-fee-for-service-payment/snfpps/pdpm.html
Prior to the PDPM, many payers were paying SNF claims that were not coded per coding guidelines; such is the case with assigning some of the status codes as a first listed diagnosis on the MDS, Section 10020B, which was commonly accepted in the past with little chance of denial. Now certain status codes will trigger the claim with an “unable to process” status and the claim will be returned to provider based on improper coding sequence. Coders should follow all coding guidelines; in your ICD-10-CM codebook, many status codes have the “unacceptable principal diagnosis symbol per Medicare code edits” appended. Also refer to the MCE Manual for more information on acceptable principal diagnosis codes at: https://www.cms.gov/Medicare/Coding/ICD10/downloads/icd10_mce27_user_manual.pdf
The following is an example of a significant coding change with PDPM:
A patient with severe degenerative osteoarthritis of the hip, undergoes a right hip replacement. After the surgery, the patient is admitted so SNF for rehabilitation.
Prior to PDPM, this scenario would likely have had Z96.641 Presence of right artificial hip joint, assigned as the first listed code on the MDS Assessment, Section 10020B. After PDPM, this code Z96.641 is on the RTP list and may not be assigned as a first listed code; this would have triggered a denial.
Accurate coding of the admission to long term care for rehabilitation following the right hip replacement surgery would be sequenced as follows:
Z47.1 Aftercare following joint replacement surgery
Z96.641 Presence of right artificial hip joint
Per ICD-10-CM Official Coding Guidelines, aftercare codes are used when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare Z code should not be used if treatment is directed at a current, acute disease, in that case, the diagnosis code is to be used.
In the scenario above, the patient’s right hip replacement was the treatment for the acute illness or injury of the right hip. Now the patient is admitted to the SNF for rehabilitation and the condition is no longer current or acute. Therefore, the aftercare code Z47.1 is the accurate first listed diagnosis code, followed by the status code Z96.641 for the presence of right artificial hip, per the instruction in the ICD-10-CM Codebook, which says to Use additional code to identify the joint (Z96.6x).
Another example of improper coding with PDPM:
The patient presents for treatment of fracture of the lower tibia with an 8cm crushed tissue wound that required debridement. Following the surgery, the patient is admitted to SNF for rehabilitation.
In the past, the coder could have assigned:
S82.309F Unspecified fracture of lower end of unspecified tibia, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
After 10/1/2019 this code is on the RTP list.
In this case, the physician would be queried for laterality.
Once the physician responds to the query, and adds the comment that the laterality was the lower end of the right tibia, the coder accurately assigns:
S82.301F Unspecified fracture of lower end of right tibia, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
Now you see, coder education is a must. Having a strong CDI query process will also be a huge piece of this new PDPM process! And remember, regardless of hospital setting, coders must always follow official coding guidelines (just because payers may have been lax in the past, coders must apply all coding guidelines)!
Still worried? Contact STAR Medical Auditing Services! We can help with your long term care coding, auditing and CDI needs!