Obtaining the most specific medical diagnosis benefits skilled nursing facilities (SNFs) on two fronts: receiving accurate reimbursement under the Patient-Driven Payment Model (PDPM) for Medicare Part A residents and improving the quality of care for all residents, says Carol Maher, RN-BC, RAC-MTA, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.
“Often, to get a diagnosis to map from the MDS to a clinical category for the physical therapy (PT), occupational therapy (OT), or speech-language pathology (SLP) payment components under PDPM, you need a more specific diagnosis,” explains Maher. “However, it’s not all about payment. Even without the mapping problem, the resident’s medical record needs to be as accurate and complete as possible, and that includes having accurate diagnoses so that the interdisciplinary team can provide the correct treatment.”
For example, if a resident goes to see an outside provider, the face sheet that the nursing home sends with that resident should be as accurate as possible, she points out. “If the resident had a heart attack, was the myocardial infarction a STEMI (ST-segment elevation myocardial infarction) or a non-STEMI? You don’t want to leave that type of diagnosis unspecified because including the most accurate diagnosis on the nursing home face sheet could affect that outside provider’s treatment decisions and the resident’s overall quality of care.”
Some nurse assessment coordinators (NACs) rely on the hospital discharge summary as the primary source of diagnoses and ICD-10-CM codes, says Maher. “The hospital discharge summary is a good starting point. However, the diagnoses listed on it sometimes are not specific, nor are they always inclusive of all active diagnoses. The hospital discharge summary only shows what the discharging physician believes are the most important active diagnoses. You have to drill down to confirm what the active diagnoses are in the SNF and to determine the most specific diagnosis for each diagnosis the resident has.”
Potential problems with hospital diagnoses that NACs need to be on the lookout for include the following:
Unspecified ICD-10 codes
“When you are documenting diagnoses in the medical record for a SNF stay, you need to understand how documentation works in the hospital setting,” says Maher. “First, the physician must write the diagnosis, but isn’t responsible for writing the ICD-10 code.”
Why is that important? Hospital physicians, like hospital coders, have access to software that pulls up ICD-10 codes as they type in a diagnosis, says Maher. “Often, the physician just clicks on the top-listed ICD-10 code that they see, which very often is an unspecified code.”
Some NACs will then pull that unspecified ICD-10 code from the hospital records instead of finding the actual documentation of the diagnosis itself, points out Maher. “Some SNFs have had claims denied because they used unspecified ICD-10 codes that they have pulled from the hospital records but that are not mappable diagnoses under PDPM.”
Maher offers this example: In the hospital software, a physician clicks on the ICD-10 code S72.009A (fracture of unspecified part of unspecified femur, initial encounter for fracture) for a hip fracture. This diagnosis is listed on the hospital discharge summary, so the NAC adds the appropriate “D” code for a fracture of unspecified part of unspecified femur onto the SNF diagnosis list and then codes S72.009D (fracture of unspecified part of unspecified femur, subsequent encounter for fracture with routine healing) in MDS item I0020B (ICD Code/Primary Medical Condition). However, S72.009D is identified as a return-to-provider (RTP) code in the “Mapping of the ICD-10-CM Recorded in Item I0020B of the MDS Assessment to PDPM Clinical Categories” section of the PDPM ICD-10-CM Mappings FY2020 tool.
“Consequently, it will not map,” notes Maher. “This makes sense. How can you treat the fracture if you don’t know where it is? Hopefully, the physician at the hospital will have written which hip was broken so that you can code the appropriate diagnosis that will map in I0020B.”
To find that diagnosis, the NAC typically should be looking at radiology reports: X-ray reports, computerized axial tomography (CAT) scans, and magnetic resonance imaging (MRI) reports, suggests Maher. “You must dig deeply to find the most specific diagnosis available for the resident’s problems—a diagnosis that must have been written in the last 60 days and that is actively being treated. For the hip fracture, the best practice would be to obtain a copy of the X-ray, CAT scan, or MRI that has been signed by the radiologist.”
The surgical report from the hospital often is another important data point because it will list postoperative diagnoses, says Maher. “It also will give the SNF the documentation about risk that they are required to have for coding the surgical procedures that affect the primary diagnosis in MDS section J (Health Conditions), which can affect payment.”
If hospital documentation doesn’t provide a diagnosis with greater specificity, the NAC should query the resident’s attending physician to ask them to further specify the diagnosis from the hospital, says Maher. “Ask them to drill down if there is not a specific documented diagnosis. As a nurse, you can’t extrapolate or assume that you know what the diagnosis is. You have to ask the physician for the diagnosis.”
Hospital discharge summaries routinely include general diagnoses, such as congestive heart failure (CHF), notes Maher. “However, if you dig into the consult notes from the hospital, often you can find where, for example, the cardiologist saw the resident and has listed the very specific type of heart failure the resident has. For example, is it systolic, diastolic, or combined systolic and diastolic? That information should be important to the resident’s primary care physician in the facility because it makes a difference in how their heart will be treated.”
The Health Insurance Portability and Accountability Act (HIPAA) requires that all healthcare providers adhere to the ICD-10-CM Official Coding Guidelines when assigning ICD-10 diagnosis, says Maher. “In other words, you must code the ICD-10 codes as specifically as possible. Consequently, you can’t just copy over the hospital discharge summary and make it yours. You need to investigate all of the records.”
Some NACs pull over principal diagnoses from the hospital that are no longer active because they mistakenly believe that SNFs are required to use the hospital’s principal diagnosis as the principal diagnosis for SNF admission, says Maher. “The Fiscal Year (FY) 2019 Skilled Nursing Facility Prospective Payment System (SNF PPS) Final Rule clearly states that the SNF does not need to use the same primary diagnosis as the hospital, but must be treating a condition that was treated during the qualifying three-day stay.” Here’s the relevant excerpt:
As discussed in Chapter 8 of the Medicare Benefit Policy Manual, a beneficiary in a Medicare Part A SNF stay must require skilled nursing care for a condition that was treated during the qualifying hospital stay, or for a condition that arose while in the SNF for treatment of a condition for which the beneficiary was previously treated in the hospital. However, CMS recognizes that in many cases, the primary reason for SNF care may not be the same as the primary reason for the prior inpatient stay. For example, a beneficiary may be treated in a SNF for a secondary condition that arose during the prior inpatient stay but that is different from the condition that precipitated the acute inpatient stay in the first place. PDPM requires facilities to code the diagnosis that corresponds most closely to the primary reason for SNF care (in this case, the secondary condition that arose during the hospital stay) rather than the primary reason for the prior hospitalization. …
Maher offers this example: A person goes to the hospital with severe gallbladder pain. A surgeon treats the gallbladder by removing it, and the patient’s primary diagnosis in the hospital is cholecystitis. A SNF admits this resident for Part A skilled care. “The SNF can’t use the primary diagnosis of cholecystitis. The resident doesn’t have cholecystitis anymore because their gallbladder has been removed. The SNF’s primary diagnosis is aftercare of surgery on the digestive tract.”
The bottom line is that it is crucial to look at the resident’s entire medical record, says Maher. “Just because there was a diagnosis in the hospital, that does not mean that the diagnosis is still active in the SNF, and it doesn’t even mean that the resident still has that diagnosis.”
‘Resolved’ diagnoses that are still active
Hospitalists often will write on the hospital discharge summary that a diagnosis is resolved when it isn’t truly resolved, says Maher. “For example, a resident may be in the hospital receiving IV antibiotics for endocarditis or sepsis. They are then discharged from the hospital to the SNF to have the remaining six weeks of antibiotics given while in the SNF or even to be treated with therapy for the late effects of that infection, yet the discharge summary says the infection is resolved.”
In this type of scenario, some NACs have tried to work around resolved diagnoses by, for example, setting the assessment reference date (ARD) for the PPS 5-day on day 4 of the SNF stay in order to look back into the hospital stay and pull the diagnosis from before it was identified as resolved, explains Maher. “However, that isn’t a wise practice. A diagnosis that is resolved cannot drive the care plan, so it doesn’t make sense to use it as a primary diagnosis. Additionally, the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual specifically states that resolved diagnoses cannot be coded in section I (Active Diagnoses).” Here’s the relevant excerpt from the steps for assessment on page I-7 in chapter 3:
2. Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident’s current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident’s current status, or do not drive the resident’s plan of care during the 7-day look-back period, as these would be considered inactive diagnoses.”
When the NAC knows that a resolved diagnosis remains active during the SNF stay, “that is when you should query the resident’s primary care physician,” says Maher. “The attending physician can write a diagnosis addressing the continuing treatment you are providing in the SNF so that it is no longer a resolved diagnosis. And when you query, it’s important to remember to query the physician for the diagnosis, not the ICD-10 code.”
Some hospitals “resolve” diagnoses as a matter of process, points out Maher. “That is not an accurate approach, so if it happens often, you may want to enlist the help of your medical director and talk to the hospital about how it affects residents and their ability to use Medicare insurance.”
Note: AANAC's new Comprehensive Diagnosis Collection Flow Chart helps the NAC to communicate the time and effort it may take to uncover all of the resident’s conditions and comorbidities to the leadership team.
For permission to use or reproduce this article in full or in part, please complete a permissions form.
Meet the volunteers who review LTC Leader articles and FAQ content. They represent the best and brightest minds in LTC, and we thank them.