It is the goal of every skilled nursing facility (SNF) to provide quality resident care. Inaccurate ICD-10-CM coding can interrupt that goal, leading to frustration, confusion, inadequate care planning and delayed reimbursement.  Additionally, Medicare and Medicare Advantage audits could reveal inaccurate ICD-10-CM coding leading to accusations of errors, fraud, waste, abuse and even suspended reimbursement. Facilities deserve to be paid for the care they provide, but it is essential they avoid coding errors that lead to improper billing.

In 2019, the Centers for Medicare and Medicaid Services (CMS) changed to a new payment system for SNFs called the Patient-Driven Payment Model (PDPM). This change moved away from a payment model that was based primarily on the amount of reimbursable therapy minutes provided to the resident. The new model was meant to improve payment accuracy and appropriateness by focusing on the resident and his/her needs, rather than the volume of services provided.

CMS also hoped to streamline complicated and costly paperwork requirements for performing and tracking mandatory resident assessments by significantly reducing the reporting burden. At the time, CMS estimated this would save providers $2 billion over 10 years. With payments hinging on residents’ health characteristics and less focus on assessment requirements, it became essential that facilities performed careful initial assessments of residents and accurately documented their diagnoses.

New challenges with ICD-10-CM

However, some could argue that CMS’ well-intentioned new payment model created almost as many challenges as it solved. For billing and proper reimbursement, PDPM relies on the classification of the resident into a clinical category based on the primary diagnosis for the SNF stay. The payment assessment (MDS) must be coded accurately at I0020B, primary diagnosis, in order for the resident’s clinical mapping to produce an accurate PDPM code. The diagnosis that determines the resident’s primary medical condition category also describes the primary reason for admission to the SNF.

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) manual can be tricky because of the multiple coding options based on specificity. Coding utilized in acute care settings does not automatically translate to the level of care a resident may need in a post-acute care setting such as a SNF. Additionally, the appropriate diagnosis may not be obviously documented in previous records or may require physician clarification. Relying on short cuts or websites is ineffective and results in coding errors. The latest ICD-10-CM coding manual has many nuances and is regularly updated. Thus, accurate coding requires an understanding of how to utilize the ICD-10-CM coding manual and thorough investigative skills.

Coding help is available

The Compliance Store will soon host an opportunity for long-term care professionals to learn how to get the most out of PDPM. Renowned long-term care educator, Carol Maher, will teach the mastery of coding during a two-day live virtual workshop sponsored by The Compliance Store. The ICD-10-CM Coding for Post-Acute Care live virtual workshop is a must for long-term care professionals who desire quality resident care and smoother billing cycles.

Maher is the director of education for Hansen Hunter & Co. P.C. She is a Certified Professional Coder (CPC) and a Board-Certified Gerontological Registered Nurse with more than 30 years of long term care experience. She is also the author of Long-Term Care MDS Coordinator’s Field Guide (HCPRO 2016). 

The course is open to The Compliance Store subscribers and non-subscribers. This two-day course will walk participants through the process of determining and identifying the most appropriate ICD-10-CM codes. Participants will also actively use the correct process for using the ICD-10-CM manual, from identification of the main term through the final code selection and review the ICD-10-CM coding guidelines and chapter-specific guidelines. The webinar will provide 14.0 contact hours for licensed nurses and 13.5 hours for NHAs (NAB).

Join us for this special educational event and never be uncertain again about coding diagnoses! Click here to save your seat!