Harmony Healthcare International (HHI) Blog

ICD-10 Coding and Skilled Nursing Care

Kris Quote Blog MDS Nurses


Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency • Survey

MDS Nurses do not need to be expert coders, but it is essential that they connect the dots between the diagnoses and rationale for skilled care.  

PDPM flips the script and highlights nursing care.  For the last 2 decades, therapy dominated the RUGs classification at 92%.  This means that skilled claims leaned on therapy as the skilled qualifier.  Although Harmony Healthcare International (HHI) consistently preaches that “nursing rules the world” and that “nursing always anchors the patient for skilled coverage”, many providers may have relied solely on therapy for coverage.

In these instances, providers are at risk for denial of payment if the supporting documentation is not reflective of the nursing skilled service and the relationship to the ICD-10 code. Hence it is important to re-educate staff on the parameters for skilled care. 

Certification Form Skilled Nursing

Below are the 4 pillars for nursing skilled coverage:

  1. Inherent Complexity: This refers to services that require the inherent skills of a nurse: 
  • IV Feeding
  • IV Medications
  • Suctioning
  • Tracheostomy Care
  • Ulcer Care
  • Tube Feedings
  • Respiratory Therapy
  • Care for Surgical Wounds or Open Lesions
  • Management of Diabetes with Injections
  • Transfusions
  • Chemotherapy
  • Early Post-Operative Colostomy Care 

Example Rationale for Skilled Nursing Inherent Complexity

 “This patient requires daily skilled nursing secondary to the inherent complexity of wound care.”

  1. Observation and Assessment: This refers to conditions where there is a “reasonable probability or possibility” for: 
  • Complications
  • Potential for further acute episodes
  • Need to identify and evaluate the need for modification of treatment
  • Evaluation of initiation of additional medical procedures 

Observation and assessment skills Include, but are not limited to, fever, dehydration, septicemia, pneumonia, nutritional risk, chemotherapy, weight loss, blood sugar control, impaired cognition, mood and behavior conditions. 

In conjunction with identifying the nursing assessment, it is imperative to document the defined assessment on a daily basisThis may include neurological, respiratory, cardiac, circulatory, pain/sensation, nutritional, gastrointestinal, genitourinary, musculoskeletal, and skin assessments. 

Example Rationale for Skilled Nursing Observation and Assessment 

“This patient requires daily skilled nursing observation and assessment of signs and symptoms related to exacerbation of pneumonia.” 

Remember:  Skilled observation is required until the treatment regimen is essentially stabilized.

  1. Management and Evaluation of a Care Plan: This refers to the patient’s total condition.  Based on the Physician’s orders, these services require the involvement of skilled nursing to: 
  • Meet the Resident’s Medical Needs
  • Promote Recovery
  • Ensure Medical Safety 

This area includes the: 

  • Sum Total of Unskilled Services
  • Potential for Serious Complications
  • High Probability of Relapse
  • Recovery and Safety
  • Meet Medical Needs
  • Includes Resident’s Overall Condition 

Nursing narratives may elaborate on surgical sites, circulatory status, status of fractures, maintenance of weight bearing status, skin care and labs. 

Example Rationale for Skilled Nursing Management and Evaluation of a Care Plan

 “This patient requires daily skilled nursing for overall management and evaluation of Care Plan to ensure medical safety and promote recovery due to his increasing and changing medication schedule related to immobility and decreased cognition.”

  1. Teaching and Training: This refers to activities that require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen. 

Topics to document may include: 

  • Colostomy Care
  • Insulin Administration
  • Prosthesis Management
  • Catheter Care
  • G-Tube Feedings
  • IV Access Sites
  • Braces, splints and Orthotics
  • Wound Dressings and Skin Treatments 

Example Rationale for Skilled Nursing Teaching and Training 

“This patient requires daily skilled nursing for teaching and training of self-administration of insulin injections.”


These above narratives are important for understanding the skilled stay for all SNF Medicare Part A residents.  Incorporating into the Certification form is equally important.

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

harmony20 October 29-30 2020 Encore Boston Harbor

Topics: ICD-10

Kris Mastrangelo, OTR/L, LNHA, MBA


Kris Mastrangelo, OTR/L, LNHA, MBA

Data collection is the foundation for monitoring progress, but, in itself is a daunting task

Get your FREE PDPM Revenue Analysis

Start Here

Get Expert Tips in your inbox

Subscribe to our newsletter

Latest Blog Posts

ABN and NOMNC - Q and A Series: Part IV

Read Full Post

COVID-19 1135 Waivers Effective May 10, 2021

Read Full Post

Survey Citations “Sweet 16 Strategies for Success” Part 2 of 2

Read Full Post

ABN and NOMNC - Q and A Series: Part IV

Read Full Post

COVID-19 1135 Waivers Effective May 10, 2021

Read Full Post

ABN and NOMNC - Q and A Series: Part IV

Read Full Post

COVID-19 1135 Waivers Effective May 10, 2021

Read Full Post