REIMBURSEMENT AND ICD-10 CODING - arhealthcare.com of ICD10 Co… · qSome codes may map to more...
Transcript of REIMBURSEMENT AND ICD-10 CODING - arhealthcare.com of ICD10 Co… · qSome codes may map to more...
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REIMBURSEMENTAND
ICD-10 CODING
December 2018 - RB Health Partners, Inc.
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Objectives
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Objectives
Ø Participants will learn Ø The role of diagnosis coding in the Patient
Driven Payment Model (PDPM).Ø The importance of correct diagnosis
identification and codingØ The impact of diagnosis coding on the revenue
cycleØ How to prepare for increased importance of
diagnosis coding with the implementation of PDPM
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Diagnoses and PDPM
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Patient-Driven Payment Model (PDPM) OverviewPDPM uses clinical conditions to determine the resident’s payment category, rather than the amount of therapy provided.
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PDPM Overview
PDPM is composed of five case mix adjusted payment components and one non-case mix component:
q Physical Therapy (PT) q Occupational Therapy (OT) q Speech Language Pathology (SLP) q Nursing q Non-Therapy Ancillaries Services (NTA)q Non-Case Mix Component
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PDPM Overview
• All residents will be classified into PT, OT, and SLP categories regardless of whether they are on therapy case load.
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PT and OT Components
Ø PT and OT Case Mix are calculated in the same manner, but paid separately based on separate case-mix indices.
Ø Drivers of PT and OT componentq Primary reason for skilled stay
§ Utilizes diagnosis codes to classify residents into on of four PT and OT clinical categories
q Function Score
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PT and OT Components
Selecting of the primary reason for skilled stay:
q Determine resident’s primary diagnosis
§ This code, or codes, must be entered into MDS Item
I8000.
q Utilizing the primary diagnosis identify one of the
four clinical categories.
§ Major joint replacement or spinal surgery
§ Other orthopedic
§ Non-orthopedic surgery
§ Medical Management
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PT and OT Components
Selecting of the primary reason for skilled stay: q Some codes may map to more than one clinical
category q Further delineation may be made into a surgical
category based on specific procedures that occurred during inpatient hospitalization§ The ICD-10-PCS (procedure code), if utilized to map
the resident into a surgical clinical category, must be recorded on the second line of item I8000.
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PT and OT ComponentsMajor Joint Replacement or Spinal Surgery
ICD-10-CM Code DescriptionM970- Periprosthetic fracture around internal prosthetic hip joint
M971- Periprosthetic fracture around internal prosthetic knee joint
M973- Periprosthetic fracture around internal prosthetic shoulder joint
S120- Unspecified displaced (or nondisplaced) fracture of first cervical vertebra
S22001- Stable burst fracture of unspecified thoracic vertebra
S32001- Stable burst fracture of unspecified lumbar vertebra
T84010- Broken internal right hip prosthesis
T84011- Broken internal left hip prosthesis
T84012- Broken internal right knee prosthesis
T84013- Broken internal left knee prosthesis
Z471 Aftercare following joint replacement surgery
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PT and OT Components
PT and OT Clinical Category
Primary Diagnosis Clinical Category
Major Joint Replacement or Spinal Surgery
• Major Joint Replacement• Spinal Surgery
Other Orthopedic • Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)
• Non-Surgical Orthopedic/Musculoskeletal
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PT and OT Clinical Categories
PT and OT Clinical Category
Primary Diagnosis Clinical Category
Non-Orthopedic Surgery and Acute Neurologic
• Non-Orthopedic Surgery• Acute Neurologic
Medical Management • Acute Infections• Cardiovascular and
Coagulations• Pulmonary• Cancer• Medical Management
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16 PT and OT Case-Mix GroupsClinical Category Function Score PT Case Mix Group CMI
Major Joint Replacement or Spinal Surgery 0-5 TA 1.53Major Joint Replacement or Spinal Surgery 6-9 TB 1.69Major Joint Replacement or Spinal Surgery 10-23 TC 1.88Major Joint Replacement or Spinal Surgery 24 TD 1.92Other Orthopedic 0-5 TE 1.42Other Orthopedic 6-9 TF 1.61Other Orthopedic 10-23 TG 1.67Other Orthopedic 24 TH 1.16Medical Management 0-5 TI 1.13Medical Management 6-9 TJ 1.42Medical Management 10-23 TK 1.52Medical Management 24 TL 1.09Non-Orthopedic Surgery and Acute Neurologic 0-5 TM 1.27Non-Orthopedic Surgery and Acute Neurologic 6-9 TN 1.48Non-Orthopedic Surgery and Acute Neurologic 10-23 TO 1.55Non-Orthopedic Surgery and Acute Neurologic 24 TP 1.08
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SLP Component
Ø ST Case Mix utilizes diagnosis codes to classify residents into neurologic or non-neurologic clinical category q It also utilizes diagnosis coding to capture SLP
related comorbidities.§ Oral Cancers§ Speech Language Deficits
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SLP Component
Ø Five Characteristics that will impact the SLP Componentq Acute Neurologic or Non-Neurologicq SLP-Related Comorbidityq Cognitive Impairmentq Mechanically Altered Dietq Swallowing Disorder
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SLP Component
The following comorbidities will be pulled from Section I – Active Conditions of the MDSØ Item I4300. AphasiaØ Item I4500. CVA, TIA, StrokeØ Item I4900. Hemiplegia or HemiparesisØ Item I5500. Traumatic Brain Injury
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SLP Component
The following comorbidities will be pulled from Section I – Active Conditions of the MDSØ Item I8000.
q Laryngeal Cancerq Apraxiaq Dysphagiaq ALSq Oral Cancersq Speech and Language Deficits
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SLP Component
Condition ICD-10-CM Code Description
Speech and Language Deficits I69.928 Other speech and language deficits following unspecified cerebrovascular
disease
Speech and Language Deficits I69.920 Aphasia following unspecified cerebrovascular disease
Speech and Language Deficits I69.921 Dysphasia following unspecified cerebrovascular disease
Speech and Language Deficits I69.922 Dysarthria following unspecified cerebrovascular disease
Speech and Language Deficits I69.923 Fluency disorder following unspecified cerebrovascular disease
Speech and Language Deficits I69.928 Other speech and language deficits following unspecified cerebrovascular
disease
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SLP Component
Additional factors utilized to adjust case mix index calculationØ Mechanically Altered Diet
q Determined by K0510C2Ø Swallowing Disorder
q Determined by K0100Ø Cognitive Impairment
q Determined by C0500 or C1000
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12 SLP Case-Mix Groups
Presence of Acute Neurologic Condition, SLP-Related
Comorbidity, or Cognitive Impairment
Mechanically Altered Diet or
Swallowing DisorderSLP Case Mix Group CMI
None Neither SA 0.68None Either SB 1.82None Both SC 2.66Any one Neither SD 1.46Any one Either SE 2.33Any one Both SF 2.97Any two Neither SG 2.04Any two Either SH 2.85Any two Both SI 3.51All three Neither SJ 2.98All three Either SK 3.69All three Both SL 4.19
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Nursing Component
Ø Utilizes modified version of the RUG-IV Nursing Categoriesq Reduced to 25 PDPM RUGS from the original 43q Diagnosis codes are used to further classify
residents into one of the 25 PDPM RUG groups.Ø Nursing Function Score based on Section GG
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Nursing Component
Ø Further division is based on the presence of the following conditions or services:q Tracheostomy and Ventilator/Respiratorq Infection Isolationq Depressionq Restorative Nursing Services
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Nursing Component
Ø RUGs are grouped into six categories
q Extensive Services
q Special Care High
q Special Care Low
q Clinically Complex
q Behavioral Cognitive Symptoms
q Reduced Physical Function
Ø Three categories utilize diagnosis and coding
from section I of the MDS.
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Nursing Component
Ø Special Care High Ø Diagnosis Coding in from Section I
q Septicemia (I2100)q Diabetes (I2900) with both of the following
§ (N0350A) Insulin injections all 7 days§ (N0350B) Insulin order changes on 2 or more
days
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Nursing Component
Ø Special Care High Ø Diagnosis Coding in from Section I
q Quadriplegia (I5100) with§ Nursing Function Score greater than or equal to
eleven (11)q COPD (I6200) and
§ J1100C SOB when lying flat
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Nursing Component
Ø Special Care Highq Fever (J1550A) and one of the following:
q Pneumonia (I2000)q Vomiting (J1550B)q Weight Loss (K0300, 1 or 2)q Feeding Tube (K0510B1 or K0510B2)
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Nursing Component
Ø Special Care Lowq Diagnosis Coding
q Cerebral palsy (I4400) and§ Nursing Function Score of 11 or greater
q Multiple Sclerosis (I5200) and § Nursing Function Score of 11 or greater
q Parkinson's (I5300) and § Nursing Function Score of 11 or greater
q Respiratory Failure (I6300) and § Oxygen therapy while a resident (0100C2)
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Nursing Component
Ø Clinically Complexq Diagnosis Coding
q Pneumonia (I2000) and§ Nursing Function Score of 11 or greater
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Nursing Case Mix Groups
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Non-Therapy Ancillary (NTA)ComponentØ Utilizes 50 diagnosis codes and extensive
services to identify additional comorbiditiesØ Must be coded on the UB04 or MDSØ Utilizes a points scale from 1 to 8 to calculate
comorbidity score
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NTA Component
Ø The following conditions will be pulled from Section I – Active Conditions of the MDS.Ø Multiple Sclerosis (I5200)Ø Asthma, COPD, Chronic Lung Disease (I6200)Ø Wound Infections (I2500)Ø Diabetes Mellitus (DM) (I2900)Ø Multi-Drug Resistant Organism (MDRO) (I1700)Ø Malnutrition (I5600)
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NTA Component
Ø The following conditions will be pulled from Section I – Active Conditions of the MDS.Ø I8000 – Additional Diagnoses
q Lung Transplant Statusq Major Organ Transplant Status, Except Lungq Opportunistic Infectionsq Bone, Joint, Muscle Infections/Necrosis, Except
Aseptic Necrosis of Boneq Chronic Myeloid Leukemiaq Endocarditis
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NTA Component
Ø The following conditions will be pulled from Section I – Active Conditions of the MDS.Ø I8000 – Additional Diagnoses
q Immune Disordersq End-Stage Liver Diseaseq Narcolepsy and Cataplexyq Cystic Fibrosisq Specified Hereditary Metabolic and Immune
Disordersq Morbid Obesity
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NTA Component
Ø The following conditions will be pulled from Section I – Active Conditions of the MDS.Ø I8000 – Additional Diagnoses
q Psoriatic Arthropathy and Systemic Sclerosisq Chronic Pancreatitisq Proliferative Diabetic Retinopathy and Vitreous
Hemorrhageq Complications of Specified Implanted Device or
Graftq Inflammatory Bowel Disease
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NTA Component
Ø The following conditions will be pulled from Section I – Active Conditions of the MDS.Ø I8000 – Additional Diagnoses
q Aseptic Necrosis of Boneq Cardio-Respiratory Failure and Shockq Myelodysplastic Syndromes and Myelofibrosisq Systemic Lupus Erythematosus, Other
Connective Tissue Disorders, and Inflammatory Hemorrhage
q Severe Skin Burn or Condition
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NTA Component
Ø The following conditions will be pulled from Section I – Active Conditions of the MDS.Ø I8000 – Additional Diagnoses
q Diabetic Retinopathy, Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage
q Intractable Epilepsyq Disorders of Immunityq Cirrhosis of Liverq Respiratory Arrestq Pulmonary Fibrosis & Other Lung Disorders
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NTA Component
Comorbidity Description ICD-10-CM Code ICD-10-CM Code Description
Endocarditis A0102 Typhoid fever with heart involvement
Endocarditis A1884 Tuberculosis of heart
Endocarditis A3282 Listerial endocarditis
Endocarditis A3951 Meningococcal endocarditis
Endocarditis A5203 Syphilitic endocarditis
Endocarditis A78 Q fever
Endocarditis B3321 Viral endocarditis
Endocarditis B376 Candidal endocarditis
Endocarditis I330 Acute and subacute infective endocarditis
Endocarditis I339 Acute and subacute endocarditis, unspecified
Endocarditis I38 Endocarditis, valve unspecified
Endocarditis I39 Endocarditis and heart valve disorders in diseases classified elsewhere
Endocarditis M3211 Endocarditis in systemic lupus erythematosus
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NTA Component
Ø HIV/AIDS add-onØ Applied based on the presence of ICD-10-CM
code B20 on the SNF claim.
Ø Due to the significant increase in nursing cost to care for HIV/AIDS patients, the facility will get an 18% increase in NTA category.
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NTA Case Mix Groups
NTA Comorbidity Score NTA Case Mix Group CMI
12+ NA 3.259-11 NB 2.536-8 NC 1.853-5 ND 1.341-2 NE 0.960 NF 0.72
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Coding Pitfalls and Tips
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Principal Diagnosis
Ø The Principal Diagnosis: is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”. Ø This definition has been expanded to include ALL
non-outpatient settings including SNFs / LTC facilities.
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Principal Diagnosis43
Ø When a patient is treated for an acute condition in the hospital and transferred to a SNF for rehabq The acute condition, if still present is coded as the
first listed/principal diagnosis.q The aftercare is coded as the first listed/principal
diagnosis, if the acute condition is no longer present.
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Principal Diagnosis44
Ø When a patient transitions to long term care or returns from hospital stay for continued long term careq The chronic condition, that requires continued stay
for long term care is the first listed/principal diagnosis.
q The acute condition or aftercare is sequenced as the first additional/secondary diagnosis.
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Additional Diagnoses45
Ø Secondary/Additional Diagnoses – conditions that coexist at the time of admission, that develop subsequently during the resident’s stay or that affect the treatment the resident receives or the resident’s length of stay.q Diagnosis that support both the Principle Dx. This
is where you would include the therapy treatment diagnosis codes as they support the Admit Dx
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Additional Diagnoses46
Ø Medicare Claims Processing Manual, Chapter Six, page 33, indicates the Principal Diagnosis and up to eight additional diagnosis codes are included in the claims review process.Ø This makes it imperative to get the most pertinent
diagnoses requiring skilled services in the top 8 boxes of this section.
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Common Coding Errors47
Ø Incorrect selection of principal diagnosisØ Coding and Sequencing of Hypertension (HTN)
with Chronic kidney disease (CKD)Ø Coding External Causes (V00-Y99)Ø Coding UTI without meeting all of the criteria
per the Resident Assessment Instrument (RAI) Manual
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Common Coding Errors48
Ø Coding Aftercare codes (Z codes) with injury or fracture codes with a 7th character that identifies the encounter type
Ø Incorrect 7th character selection for injury and fracture codes to identify the encounter type
Ø Coding conditions to a lower or higher level of specificity than provider documentation supports
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Common Coding Errors49
Ø Coding acute condition, when conditions is resolved and skilled care is focused on the sequela or aftercare
Ø Coding symptoms with presence of a definitive diagnosis
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Risks of Inaccurate Coding
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Risks of Incorrect Coding51
Ø Inaccurate health recordØ Incomplete or inaccurate data on the MDSØ Incomplete or inaccurate data on the UB04
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Inaccurate Health Record52
Ø Risk ManagementØ Diagnosis of osteoporosis in a resident that
obtains a fracture after rolling out of the bed in lowest position onto fall mats. q Coding guidelines indicate that the fracture may
be coded as a pathologic fracture.
Ø Quality CareØ Resident specific care based in part on their
specific diagnoses and other care needs.
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Incomplete/Inaccurate MDS53
Ø Care PlanningØ Diagnoses aid in identification of problems and
determination of interventionsØ Quality Measures
Ø Percentage of Short Stay Residents with Pressure Ulcers that are New or Worseningq Includes Covariates related to diabetes or
peripheral vascular disease coded in Section I
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Incomplete/Inaccurate UB54
Ø Claims Denials
Ø Remittance advice informs of invalid diagnosis, but does not specify which code or sequence
Ø Quality Measures
Ø SNF Readmission Measure (SNFRM)
q Exclusions include hospitalized for primary diagnosis related to medical (non-surgical)
treatment of cancer
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Planning
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What’s Next56
Ø Complete routine coding and MDS auditsØ Ensure staff have current ICD-10-CM code
booksØ Updated every October 1st
Ø Provide staff with basic ICD-10-CM trainingØ Provide staff with PDPM training
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What’s Next57
Ø Ensure that all disciplines are utilizing the
same primary diagnosis
Ø Review diagnosis coding during Triple Check
(Pre-Bill) meeting
Ø Review code updates effective October 1st and
revise codes for current residents, as needed
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Questions???
Q & A 58
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You may also contact Robin A. Bleier, President with regard to this or other services at [email protected] or call us at 727.786.3032.
Thank you for your participation
To learn more about this topic please contact Heather Py, RHIT, CCS, CHPS, RAC-CT, Director of Health Information Management at [email protected].
2018 © RB Health Partners, Inc.