SNF ICD-10 Diagnosis Coding Perils
Author: Leslie Finnerty
Despite the International Statistical Classification of Diseases 10th revision (ICD-10) diagnosis coding’s October 2015 implementation, some skilled nursing facility (SNF) providers struggle with capturing accurate information to reflect post-acute care. SNF providers often don’t have certified coders on staff, leaving clinicians and medical record clerks with little to no formal training responsible for coding. Although diagnosis coding in the SNF environment may not have a direct effect on reimbursement methodology, it’s key to reflecting the care needed to support services billed.
Common Diagnosis Coding Perils
Coding diagnoses as acute for after care of the acute diagnosis:
- SNF claims containing diagnosis codes for injury or other external causes with a seventh character of “S” for sequela—a condition resulting from a previous disease or injury—or an “A” for initial encounter may be pulled by Medicare for additional development request. For SNF claims, typically a seventh character of “D” would be used to reflect subsequent encounters.
Admitting and primary diagnosis codes not reflecting the skilled admission’s reason:
- Capturing diagnosis code reasons for encounters as history of a condition as principal codes, including:
- Acquired absence of
- Presence of
- Long-term use of
- Diagnosis codes used to capture external causes of accidental injuries—codes beginning with the letter W—being used as principal codes versus the reason for SNF care diagnosis
Capturing diagnosis codes on claim forms that haven’t been updated or sequenced to reflect the current condition(s) for why the skilled services are being provided:
- Capturing unspecified codes as principal diagnosis
- Capturing codes on claim forms that haven’t been captured in Section I of the minimum data set (MDS) assessment
- Claims for therapy-only services not containing diagnosis codes to support both the medical and rehabilitative treatment
Coding not being captured to the correct specificity:
- ICD-10 was expanded to allow for more specific medical diagnosis coding. It’s important to code diagnoses to the correct specificity to correspond to the medical documentation.
- If a code is invalid, it will cause the claim to be rejected or returned to the provider for further processing in the payor system.
Avoid the Common Perils
These can help avoid common perils with diagnosis coding:
- Consider investing in coding training for staff with coding responsibilities.
- Accurate coding of the primary and admitting diagnoses is crucial to supporting the current medical treatment. Subsequent diagnoses used should report the reason for treatment’s story.
- The use of history of and external cause codes is appropriate after using diagnoses supporting current medical treatment.
- Codes should be reviewed to determine the sequelae (late effects) after the acute phase of an illness or injury.
- When determining a primary diagnosis supporting current medical treatment, clinical staff should review for any current onset of symptom(s) and the patient history for the supporting medical reason of current treatment to determine the appropriate coding to use.
- Begin the coding search through the Alphabetic Index, instead of the Tabular List.
- The placeholder X may be appropriate for some diagnoses. Refer to the ICD-10 coding manual for guidance.
- Clinical staff should review code additions to identify if more specific codes are available to use prior to capturing an unspecified code.
- Diagnoses should be reviewed and resequenced upon readmission.
- SNFs should have frequent Medicare meetings, and—as a part of these meetings—the codes captured in Section I of the MDS should be referenced to the codes captured elsewhere in the resident’s medical record.
- Claim forms should be reviewed monthly with the interdisciplinary team to ensure the proper codes and sequencing of codes are pulling to the claim forms prior to submitting claims to payors.
- Software systems should be updated annually for coding changes to ensure updated codes are chosen.
- SNFs should obtain updated coding manuals as Centers for Medicare & Medicaid Services (CMS) changes are published.
Contact your BKD advisor if you have questions.