Your ICD-10 Coding Ability and the Patient-Driven Payment Model

Posted on October 6th, 2019 at 1:00 PM

Skilled nursing facilities (SNFs) and home healthcare agencies are both grappling with tremendous changes to payment models by the Centers for Medicare and Medicaid Services (CMS). On October 1, 2019, the care of patients admitted to SNFs under Medicare’s Part A will no longer be billable according to the minutes of therapy (and nursing resources) utilized. This is part of the CMS shift toward value-based healthcare payment models.

Instead of adherence to the Resource Utilization Group (RUG-IV) classification model, you – as a SNF administrator, medical director, physician, and/or other staff member – will need to adjust to billing for the care of Medicare-enrolled patients (who represent the majority of SNF patients) under the rules of the Patient-Driven Payment Model (PDPM). Required under the PDPM is accurate diagnosis coding (which guides the reimbursements for therapy and resources provided to the SNF for the care of the given patient). Therefore, your ICD-10 coding accuracy is crucial.

By utilizing the PDPM Mapper – a free downloadable app – you can expedite the ICD-10 coding of patients in order to maximize the revenues you receive for Medicare-covered patients admitted to your SNF. The PDPM completely differs from the RUG-IV in that it will focus for determination of payment on the individualized needs (within its five case-mix groups), characteristics, and outcome goals of each patient (per a recent CMS training presentation).

The following describes two of the 10 clinical categories assigned to SNF patients under the PDPM (and based on the primary diagnosis documented as necessitating the SNF stay), as well as some of the CMS-mandated Minimum Data Set (MDS) coding changes fostered by the switch from RUG-IV to PDPM rules adherence.

Major Joint Replacement or Spinal Surgery

In senior-aged adults, knee, hip, and/or vertebral disc surgery often results in transfer to a SNF for physical therapy and recovery of function. According to an article in 2017 in the Journal of Arthroplasty, the most commonly utilized post-acute care setting as a discharge destination following joint replacement surgery is a SNF.

In order to illustrate the complexity of PDPM rules, the following are the four PDPM payment groups (documentation options) described by the aforementioned CMS training presentation – applicable to physical therapy (PT) and occupational therapy (OT) – where joint replacement is the primary diagnosis for SNF admission:

  1. PT and OT function score of 0-5: PT and OT Case Mix Group - TA; PT CMI (1.53) OT CMI (1.49).

  2. PT and OT function score of 6-9: PT and OT Case Mix Group - TB; PT CMI (1.69) OT CMI (1.63).

  3. PT and OT function score of 10-23: PT and OT Case Mix Group - TC; PT CMI (1.88) OT CMI (1.68).

  4. PT and OT function score of 24: PT and OT Case Mix Group - TD; PT CMI (1.92) OT CMI (1.53).

Acute Infections

Community-acquired pneumonia occurs in 18 of every 1,000 adults aged 65 and older, and one recognized reason is decreased immune function. Meanwhile, the US National Center for Health Statistics reports that only 68.9 percent of adults who are at least 65 years old have received a preventive pneumonia shot. Urinary tract and skin infections are also more common in older-aged adults. Debilitated patients following a course of treatment are often transferred from a hospital to a SNF for recuperation (and inclusive of PT consequent to a prolonged bedridden state while in the hospital).

A concern for SNF administrators is that CMS reimbursement for PT (and other therapies) will be lower under the PDPM than when each therapy session was the basis for payment under the RUG-IV (rather than linked to documented patient characteristics and outcome goals per the PDPM). Similarly – for home healthcare agencies under the PDGM – a fear has been reduced overall reimbursements for patient care from the CMS (as reported in an article in Home Health Care News in 2019).

With such a major change facing your SNF under the PDPM – most likely involving a considerable amount of your “on the job” time – utilizing the PDPM Mapper can decrease the likelihood of receiving a denial-of-payment for a claim due to entry of an erroneous CPT-10 code, and thereby necessitating a re-submittal of that Medicare claim.