Under the Payment-Driven Payment Model (PDPM), the selection of the primary medical diagnosis recorded in the Minimum Data Set (MDS) item I0020B plays a factor in the Medicare Prospective Payment System (PPS) methodology.
Understanding the International Classification of Diseases (ICD)-10 coding guidelines is one step; figuring out the Centers for Medicare and Medicaid Services (CMS) PDPM ICD-10-CM Mappings Fiscal Year 2021 is another key element for the reimbursement calculation.
Assigning ICD-10 codes must be at the highest degree of specificity based on the provider-documented medical records. Records include the history and physical, recent hospital discharge summary, signed physician’s orders, provider consults, progress notes, and pertinent diagnostic reports. It is important to communicate with the provider to ensure that necessary information is documented in the medical record within the assessment look-back period to identify the appropriate diagnosis codes.
Let us discuss the coding for major joint replacement conditions.
When is it appropriate to use the aftercare ICD-10 Z codes as the primary medical diagnosis in MDS item I0020B?
According to the CMS ICD-10-CM Official Guidelines for Coding and Reporting for Fiscal Year 2021, the aftercare Z codes should not be used for aftercare of traumatic fractures. For aftercare of a traumatic fracture, assign the acute fracture code with the appropriate 7th character. Here are examples of the difference:
Example 1: A patient with severe degenerative osteoarthritis of the right hip, underwent right hip arthroplasty. MDS item I0020B, the primary diagnosis is Z47.1 – Aftercare following joint replacement surgery and MDS item J2310: Hip replacement, partial or total, should be checked. This would fall under the Major Joint Replacement or Spinal Surgery PDPM Clinical Category.
Example 2: A patient sustained a right displaced intertrochanteric fracture of the femur from a fall and had a right hip arthroplasty. MDS item I0020B, the primary diagnosis is S72.141D – Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and MDS item J2310: Hip replacement, partial or total, should be checked. The coding on the MDS would map to the Major Joint Replacement or Spinal Surgery PDPM Clinical Category.
If example 2 were incorrectly coded a hip fracture repair, MDS item J2510, this information would map to the Orthopedic PDPM Clinical Category.
Refer to the CMS PDPM Mapping for the ICD-10-CM recorded in item I0020B of the MDS Assessment to PDPM Clinical Categories shown below. Note: pay close attention to the fourth column – Default Clinical Category and the fifth column – Resident Had a Major Procedure during the Prior Inpatient Stay that Impacts the SNF Care Plan.
| Mapping of the ICD-10-CM Recorded in Item I0020B of the MDS Assessment to PDPM Clinical Categories | ||||
| Overview | ||||
| Sort Order | ICD-10-CM Code | ICD-10-CM Code Description | Default Clinical Category | Resident Had a Major Procedure During the Prior Inpatient Stay that Impacts the SNF Care Plan? |
| 43967 | S72141D | Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing | Non-Surgical Orthopedic/Musculoskeletal | Maybe Eligible for One of the Two Orthopedic surgery Categories |
Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM
The MDS coding has several elements that affect patient reimbursement classification. Applying the ICD-10 coding guidelines and accurately recording the MDS item(s) under the recent major surgery requiring active SNF care would calculate to the appropriate PDPM Clinical category.
How Can LW Consulting, Inc. Help?
- LW Consulting, Inc. (LWCI) can provide customized training for your IDT on the ICD-10 coding, MDS training and PDPM accuracy documentation and decisions.
If you have questions regarding PDPM, MDS, or other skilled nursing-related policies and procedures, contact Kay Hashagen at (410) 777-5999 or email [email protected].
