MHCA Coding and PDPM - cdn.ymaws.com · •ICD‐10 coding more important than ever •PDPM...

2/20/2020

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WEALTH ADVISORY | OUTSOURCING | AUDIT, TAX, AND CONSULTING

Investment advisory services are offered through CliftonLarsonAllen Wealth Advisors, LLC, an SEC‐registered investment advisor

©2019 CliftonLarsonAllen LLP

Deb Freeland, CPA

Principal at CLA

Sandy Giangreco Brown, BS, RHIT, CHC, CCS,

CCS‐P, CPC, COC, PCS, COBGC

Director of Coding and Revenue Integrity

The Impact of Coding on PDPM and Reimbursement


Create Opportunities

Disclaimers

The information contained herein is general in nature and is not intended, and should not be construed, as legal, accounting, or tax advice or opinion provided by CliftonLarsonAllen LLP to the user. The user also is cautioned that this material may not be applicable to, or suitable for, the user’s specific circumstances or needs, and may require consideration of non‐tax and other tax factors if any action is to be contemplated. The user should contact his or her CliftonLarsonAllen LLP or other tax professional prior to taking any action based upon this information. CliftonLarsonAllen LLP assumes no obligation to inform the user of any changes in tax laws or other factors that could affect the information contained herein.

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About CLA

• A professional services firm with three distinct business lines– Wealth Advisory

– Outsourcing

– Audit, Tax, and Consulting

• More than 5,400 employees

• Offices coast to coast

• Serving 8,300+ health care organizations Investment advisory services are offered through CliftonLarsonAllen Wealth Advisors, LLC.

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Speaker Introductions

• Deb Freeland is a principal in CLA’s health care practice specializing in reimbursement services for senior living facilities and hospitals. She has extensive experience handling the distinctive issues facing health care organizations in today’s challenging environment.

• Sandy Giangreco Brown is a Director of Coding and Revenue Integrity who performs coding reviews and education sessions for providers, clinical staff, coding and billing staff. She has more than 30 years experience in healthcare and speaks on a national level about coding, reimbursement and compliance issues and opportunities.

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Learning Objectives

At the end of this session, you will be able to:

• Understand how ICD‐10 coding is utilized in the calculation of the PDPM rate components and how coding impacts reimbursement.

• Explore the interrelationship between ICD‐10 coding, MDS assessments and billing.

• Identify potential operational changes that may be necessary to sustain your organization during the transition to PDPM.

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Overview of Important of ICD‐10 Items

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Coding Basics

• The ICD‐10‐CM for the Primary Diagnosis is the key determinant of payment

• The Primary Diagnosis is likely to be different from the reason for the hospital stay

• ICD‐10‐CM information is also used to assign a patient to a clinical category for the therapy service component

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Importance of ICD‐10 under PDPM

• PDPM utilizes the patient’s ICD‐10 diagnosis to categorize a patient into one of ten clinical categories

• Diagnosis code is the diagnosis that is the primary reason for the Part A SNF staff

• Must map to SNF PDPM Clinical Category Mapping

• Specificity will be key under PDPM

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Significant Change in Practice

• Primary skilled diagnosis has not played such a major role in the past

• Current MDS directions for entering diagnoses in I8000 indicate to only include an “additional active diagnosis” in I8000 – Specificity of that active diagnosis will now be impactful

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ICD‐10 Impact on PDPM components

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PDPM Flowchart – PT+OT

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PT and OT are classified into the same category but each component is assigned a different case mix adjustment factor



PDPM Clinical Categories

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Source: CMS PDPM_Face_Sheet_Template_Payment_Overview_Final

A mapping of the ICD‐10 diagnosis and/or surgical category used to classify to the 10 clinical categories is at https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/SNFPPS/PDPM.html

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PT & OT Clinical Category Mapping

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PDPM Clinical Categories PT & OT Clinical Categories

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Acute neurologic

Non‐Orthopedic Surgery

Non‐Surgical orthopedic/Musculoskeletal

Orthopedic‐Surgical Extremities Not Major Joint

Medical Management

Cancer

Pulmonary

Cardiovascular & Coagulations

Acute Infections

Non‐Orthopedic Surgery & Acute neurologic

Other Orthopedic

Medical Management



Example of Mapping to Clinical Category

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Source: https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/SNFPPS/PDPM.html

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Example of Mapping to Clinical Category

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PT & OT Payment Groups

Clinical Category

Section GG Function

Score

Case‐Mix

Group

Major Joint Replacement or Spinal Surgery 0‐5 TA

Major Joint Replacement or Spinal Surgery 6‐9 TB

Major Joint Replacement or Spinal Surgery 10‐23 TC

Major Joint Replacement or Spinal Surgery 24 TD

Other Orthopedic 0‐5 TE

Other Orthopedic 6‐9 TF

Other Orthopedic 10‐23 TG

Other Orthopedic 24 TH

Medical Management 0‐5 TI

Medical Management 6‐9 TJ

Medical Management 10‐23 TK

Medical Management 24 TL

Non‐Orthopedic Surgery and Acute Neurologic 0‐5 TM

Non‐Orthopedic Surgery and Acute Neurologic 6‐9 TN

Non‐Orthopedic Surgery and Acute Neurologic 10‐23 TO

Non‐Orthopedic Surgery and Acute Neurologic 24 TP

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PDPM Flowchart ‐ SLP

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Acute Neurologic, Cognitively Impaired,

or SLP Related Comorbidity

0

1

2

3

Mechanically Altered Diet or Swallowing

Disorder

Neither

Either

Both



SLP Comorbidities

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Source: https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/SNFPPS/Downloads/MDS_Manual_Ch_6_PDPM_508.pdf

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SLP Comorbidities and ICD‐10 Mapping

• Mapping between ICD‐10 codes and SLP comorbidities is available at https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/SNFPPS/PDPM.html

• Maps the ICD‐10‐CM recorded in I0020B of the MDS assessment to the clinical categories for resident classification

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SLP ICD‐10‐CM Mapping

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SLP Payment Groups

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Presence of Acute Neurologic condition,

SLP Related comorbidity, or Cognitive

Impairment

Mechanically Altered

Diet or Swallowing

Disorder

SLP Case

Mix

Group

None Neither SA

None Either SB

None Both SC

Any One Neither SD

Any One Either SE

Any One Both SF

Any Two Neither SG

Any Two Either SH

Any Two Both SI

All Three Neither SJ

All Three Either SK

All Three Both SL



MDS Example of I8000 Section

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PDPM – NTA Comorbidities and Points

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Source: https://https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/SNFPPS/Downloads/PDPM_Technical_Report_508.pdf



NTA – Comorbidities – ICD‐10 Crosswalk

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https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/SNFPPS/PDPM.html

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NTA – Comorbidities – ICD‐10 Crosswalk

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NTA Payment Groups

NTA Score

Range

NTA Case

Mix

Group

12 + NA

9‐11 NB

6‐8 NC

3‐5 ND

1‐2 NE

0 NF

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Impact of Mis‐Coding – Original Input

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Original Rate Calculation

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Corrected Clinical Category and SLP Coding

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Revised Rate Calculation

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Big Picture Considerations for ICD‐10 Coding

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SNF Primary Diagnosis

• Comes from hospital discharge summary – primary reason the individual is being admitted to the SNF

• Item I0020B (New item 10/1/18)

• Needs to be listed on UB04 and the MDS Section I, especially I8000 section

• Also listed on the Medicare certification and daily skilled notes by both nursing and therapy

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Patient Surgical History

• Items J2100‐J5000 (new items 10/1/19)

• Used to capture any major surgical procedures that occurred during hospital stay immediately preceding the SNF admission

• Similar to the active diagnoses captured in Section I, these Section J items will be in the form of checkboxes

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MDS New Section J questions about surgery

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Clinical Readiness

• MDS still drives the process

• Documentation accuracy and timeliness critical

• ICD‐10 coding more important than ever

• PDPM requires more accuracy and precision in ICD‐10 coding, but MDS nurses do NOT need to become expert coders

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Best Practices

• Determine who is currently responsible for ICD‐10 coding.

• What additional training is needed?

• What steps will you implement to verify the correct ICD‐10 code is determined and communicated to all members of the interdisciplinary team.

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ICD‐10‐CM Guidelines

• Code assignment is based on the documentation by patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis). There are a few exceptions, such as codes for the Body Mass Index (BMI), depth of non‐pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes…. only reported as secondary diagnoses.

• For social determinants of health, such as information found in categories Z55‐Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses.

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Steps to Correct Coding

• The appropriate code or codes from A00.0 through T88.9, Z00‐Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit.

• For accurate reporting of ICD‐10‐CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems or reasons for the encounter.

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• Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD‐10‐CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (codes R00‐R99) contain many, but not all codes for symptoms.




• ICD‐10‐CM provides codes to deal with encounters for circumstances other than a disease or injury. The Factors Influencing Health Status and Contact with Health Services codes (Z00‐Z99) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.

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• ICD‐10‐CM is composed of codes with either 3, 4, 5, 6 or 7 digits. Codes with three digits are included in ICD‐10‐CM as the heading of a category of codes that may be further subdivided by the use of fourth fifth digits, sixth or seventh digits which provide greater specificity.

• A three‐digit code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character extension, if applicable.




• List first the ICD‐9‐CM/ICD‐10‐CM code for the diagnosis, condition, problem or other reason for the encounter shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.

In some cases the first‐listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.

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• Do not code diagnoses documented as “probable”, “suspected”, “questionable”, “rule out”, or working diagnosis. Rather, code the condition(s) to the highest degree of certainty for that encounter, such as symptoms, signs, abnormal test results, or other reason for the visit.

• Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).




• Code all documented conditions that coexist at the time of the encounter, and require or affect patient care, treatment, or management. Do not code conditions that were previously treated and no longer exist. However, history codes (Z80‐Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

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• The subcategories for encounters for general medical examinations, Z00.0‐, provide codes for with and without abnormal findings. Should a general medical examination result in an abnormal finding, the code for general medical examination with abnormal finding should be assigned as the first listed diagnosis. A secondary code for the abnormal finding should also be coded.



Documentation Issues

• Documentation must clearly indicate the reason for the visit and any coexisting conditions that affect treatment and care.

• Documentation for each visit must stand alone.

• If practice uses a problem list, it must be updated at each visit – and referenced in the documentation for the date of service.

• Each progress note should be signed with credentials.

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Documentation Problems

• A prescription is listed but not the condition treated – e.g., the drug is for hypertension but the provider did not list hypertension in the diagnoses for that date of service.

• Provider notes a diagnosis on the encounter form but it is not documented in the chart for the date of service billed.

• Diagnoses are not linked –


CLAconnect.com

Thank you! Deb Freeland, CPAPrincipal317‐569‐[email protected]

Sandy Giangreco Brown, BS, RHIT, CHC, CCS, CCS‐P, CPC, COC, COBGC, PCS Director of Coding and Revenue Integrity970‐581‐[email protected]

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MHCA Coding and PDPM - cdn.ymaws.com · •ICD‐10 coding more important than ever •PDPM...

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