ICD-10 Coding in Post-Acute Care: PDPM for SNFs

Coding in the post-acute care world has taken on a new significance in the past five years. For those of us who are coders, this is exciting – a new healthcare arena where we can share our expertise. For those in that post-acute care world, such as those working for skilled nursing facilities (SNFs), it was also a new challenge.

Prior to Oct. 1, 2019, post-acute care facilities were paid based on the Resource Utilization Group (RUG) the resident “grouped” to. As coders, the idea of grouping is a familiar one. RUGs  are determined based on the services the resident needs. This is a basic look at how it worked: the more skilled services the resident needed, the higher the RUG; the higher the RUG, the higher the reimbursement.

In October 2019, the Patient-Driven Payment Model, or PDPM, took effect. Instead of using RUGs, the resident is now mapped into five case-mix adjusted components – Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology, Non-Therapy Ancillary, and Nursing. This is obviously a significant change from the RUG-IV, wherein the resident’s classification into a single group determined the case-mix indices and per diem rates for all case-mix adjusted components. With PDPM, each resident is classified into a separate group for each case-mix adjusted component.

Each of these components has its own associated case-mix index and per diem rate. In addition, PDPM applies variable per diem payment adjustments to three components – PT, OT, and Non -Therapy Ancillary – to account for changes in resource use over the course of a stay. While there are additional factors that determine the resident’s full per diem rate, this is a very basic overview of PDPM.

The selection of a primary diagnosis, which for those coders who code inpatient accounts can think of as a principal diagnosis, is now very important. This primary diagnosis will help map the resident into one of 10 clinical categories: Acute Infection, Acute Neurologic, Cancer, Cardiovascular and Coagulations; Major Joint Replacement or Spinal Surgery; Medical Management; Non-Orthopedic Surgery; Non-Surgical Orthopedic/Musculoskeletal; Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery); and Pulmonary.

We can think of these in terms of MS-DRGs. In MS-DRGs, we know that certain conditions are considered complications or comorbidities (CCs) or major CCs (MCCs). Secondary or additional diagnoses that are being treated or monitored are also assigned in the long-term care setting. Some of these conditions may be considered a Speech Language Pathology comorbidity or a Non-Therapy Ancillary comorbidity. 

Complete and timely documentation is vital for thorough and accurate coding. Documentation also needs to be authenticated appropriately for coding support. Long-term care facilities need to reexamine the documentation they receive on admission or transfer, not just for completeness, but also for authentication. While long-term care facilities do not assign ICD-10-PCS codes, they do need to make sure that an operative report, when applicable, is part of the transfer documentation they receive on admission. This will be reviewed to ensure that they are completing their data set accurately.

Long-term care facilities complete a special standardized data set developed by the Centers for Medicare & Medicaid Services (CMS). The OASIS (Outcome and Assessment Information Set) form is reviewed to make sure the data collected reflects the condition of the resident.

All long-term care facilities will assign ICD-10-CM codes. This means that those facilities will be expected to follow the Official Guidelines for Coding and Reporting. As credentialed and certified coding professionals, no one knows those guidelines better than we do.

This offers an exciting opportunity for those of us who code to provide guidance and assistance to a whole new arena of healthcare, where coding has reached a new level of importance. 

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Listen to senior healthcare consultant Christine Geiger’s Talk Ten Tuesday Coding Report live today during Talk Ten Tuesday with Chuck Buck and Dr. Erica Remer, 10 Eastern.