Reduce Risk of Audit With Accurate ICD-9 Coding

ICD-9/Diagnosis Coding:  Harmony frequently discusses the process of ICD-9 coding and the ordering of diagnoses for coding on the MDS and UB-04 during site visits. Often in the SNF setting there is a disconnect between the ICD-9 codes that are coded on the MDS, on therapy evaluations and the ICD-9 codes that are coded on the UB-04. Harmony recommends the facility evaluate this process to ensure the appropriate codes are being used on the UB-04.  

Harmony recommends each facility have a written policy on ICD-9 coding highlighting:

• Selection of  codes
• Maintaining and updating codes
• Communication between the clinical team and the billing team.

Harmony recommends the facility consider the following information points regarding Medicare guidelines/definitions when deciding which diagnoses are indicated:

•   Principal Diagnosis Medicare Billing Definition: The condition for which the patient was admitted to the SNF to receive skilled nursing services.

•  Admission/Principal and Primary Diagnoses: Should be the same for all newly admitted beneficiaries. With the PPS billing system, the principal diagnosis must also correlate with the Resource Utilization Group (RUG). Determining the principal and secondary diagnoses and accurate ICD-9-CM codes should be a combined effort between the facility coder and the MDS Coordinator and/or the staff member making Medicare coverage determinations.

Ongoing communication between the MDS Coordinator, the designated Medicare staff, the facility coder, and the billing office is essential for correct diagnoses and codes on the MDS and UB-04.

MDS 3.0 Section I0100-18000, Active Diagnoses (7-day look back) :

1.  
   1. Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days.
   2. Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Do not include conditions that have been resolved or have no longer affected the resident's functioning or plan of care during the last 7 days. Item I2300 UTI, has specific coding criteria and does not use the active 7-day look-back.

Secondary Diagnoses, are Medicare defined as; all conditions that coexist at the time of admission, that develop subsequently during the resident's stay, or that affect the treatment the resident receives and/or the resident's length of stay. Secondary diagnoses are conditions that:

• Are clinically evaluated.
• Are therapeutically treated.
• Require diagnostic procedures.
• Extend the length of stay.
• Increase nursing care and/or monitoring.
• Require prescribed medication.

Secondary diagnoses are sequenced and prioritized according to the skilled services needed for each resident's plan of care. List the "most skilled" diagnosis first, for example, if a resident is admitted with a diagnosis of hip fracture and a diagnosis of UTI, the hip fracture code should be listed before the UTI code.  Harmony recommends review of diagnoses that are questionably skillable and may put a claim at risk for Medical Review by the Medicare Contractor, such as dementia, Alzheimer's disease, and psychological diagnoses. These diagnoses should be coded toward the end of the diagnosis sequence on the bill and rarely if ever used as the principal or primary diagnosis.     

Contribution written by Colleen Gouldrick, RN, RAC-CT, Lead Regional Consultant and Compliance Officer for Harmony Healthcare

April 14, 2011 

Pain Assessment  & MDS 3.0

8:30AM - 3:30PM 

April 12, 2011 - Greer, SC

April 18, 2011 -  South Hadley, MA

May 18, 2011 - West Islip, NY