Harmony Healthcare International (HHI) Blog

Top 5 Strategies: ICD-10 Coding and Skilled Diagnosis


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

nursecoding-1As the name states, the Patient Driven Payment Model (PDPM) compensates by patient characteristics and the associated ICD-10 Codes.  Hence, it is imperative to identify and properly document the ICD-10 Codes that best reflect the patient’s reason for Skilled Medicare Coverage upon admission to the SNF.

There are 3 outcomes when selecting patient ICD-10 Codes:

  • Return to Provider
  • Resolved in Hospital
  • Reason for Skilled Care

Return to Provider is not a good situation because the SNF will receive no-payment until more clarification about the selected ICD-10 is submitted to the MAC and an alternative ICD-10 Code is selected.  There are 23,000 ICD-10 Codes that result in Return to Provider.

Resolved in Hospital is an ICD-10 Code that is not applicable to the SNF stay because the condition occurred while the patient was hospitalized without further treatment post discharge.  

Reason for Skilled Care is the ICD-10 Code that reflects the condition that qualifies the patient for accessing the SNF Medicare Part A Benefit.   These skilled services are attributed to a treatment or condition that arose secondary to hospitalization.

  • Example #1:
    Admitted with the following Codes/Diagnosis:
    • 41:       Fecal Impaction
    • 01:       Anticoagulated
    • 9:        Abdominal Pain
    • 0:         Dehydration
    • 32:        Diastolic CHF

The first 3 diagnosis/codes map out to return to provider.

Dehydration falls under Medical Management but was resolved at the hospital through administration of IV fluids.  

CHF was used as the patient’s primary diagnosis, because it was the reason, the patient required skilled care following fecal impaction. 

At the hospital and at the facility, the patient is being assessed for edema, lung sounds, labs, fluids, daily weights, and diuretic medication changes.

Recommended ICD-10 Code for this admission:  I50.32 Diastolic CHR

Rationale:  The problems of fecal impaction, abdominal pain and dehydration were resolved while in the hospital.  The reason the patient was not at prior level of function is due to diastolic congestive heart failure.  Therefore, the reason for admission is Diastolic CHF: ICD-10 I50.32.

  • Example #2:
    Admitted with the following Codes/Diagnosis:
    • 7:        Failure to Thrive
    • 0:         Dehydration
    • 320:      Aphasia as late effect of CVA
    • 0:        UTI

The first diagnosis above maps to "return to provider," since it is not a problem that typically requires skilled level of care. 

The concern of Dehydration was resolved during the hospital admission.  

The patient’s CVA occurred over 20 years ago and does not require skilled care and intervention.  

The patient was able to reside at home prior to admission.  The patent had an indwelling catheter for chronic urinary retention secondary to obstructive uropathy.  

Although the patient’s UTI was treated at the hospital, the patient was not able to complete treatment and ended up with sepsis.  The patient was admitted while continuing to receive antibiotic therapy.

Recommended ICD-10 Code for this admission:  N39.0 Urinary Tract Infection

Rationale:  The concerns with the Urinary Tract Infection are still being treated and the infection likely contributed to the issues with failure to thrive.

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Top 5 Strategies for successful ICD-10 Coding with Patient Driven Payment Model (PDPM):

Strategy #1:  

Review the hospital or transfer records with the interdisciplinary team to determine the reason that skilled care is required. Remember, there are 3 outcomes of ICD-10 selection:

  • Return to Provider
  • Resolved in Hospital
  • Reason for Skilled Care

Strategy #2: 

Use the CMS PDPM ICD-10 CM Mapping tool to assure the diagnosis identified is not in the “Return to Provider” category:


Strategy #3:  

Review of the NTS and Speech Co-Morbidities located in the CMS PDPM ICD-10 CM Mapping tool.

Strategy #4: 

Review the active diagnoses in the electronic system to assure that the diagnoses are accurate and current.

Strategy #5: 

Verify that the UB-04, the MDS and the ICD-10 Codes match.

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.   

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

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