Coding, Classification and Reimbursement

PDPM in LTC - codes that will be rejected 10/1/19

  • 1.  PDPM in LTC - codes that will be rejected 10/1/19

    Posted 15 days ago
    Hi, has anyone in the LTC coding field noticed that there are codes that have been accepted as Principal Diagnosis since 10/1/15, but they will be rejected as Primary Diagnosis on the MDS effective 10/1/19?

    Here are some examples:

    M62.81 Muscle weakness (generalized)

    R26.2 Difficulty in walking, not elsewhere classified

    R53.1 Weakness


    Does CMS need written feedback regarding this potential problem?

    You can download the ICD-10 Clinical Category Mapping spreadsheet here:

    Patient Driven Payment Model - Centers for Medicare & Medicaid Services





    ------------------------------
    Bill Roush, RHIA, BSHI, AHIMA-Approved ICD-10-CM Trainer
    ------------------------------


  • 2.  RE: PDPM in LTC - codes that will be rejected 10/1/19

    Posted 14 days ago
    Hi Bill,
    I can't really speak to whether or not this issue needs to be reported to CMS, but I would say that regardless of whether or not the codes you used as examples are permitted to be primary diagnoses, they really shouldn't be reported as primary. M62.81 and pretty much any R code are vague and secondary. The primary diagnosis should be the underlying condition. Why is this person weak? What is causing the difficulty with walking? If such an underlying condition is not documented, then there should really be a discussion with the physician, perhaps even an official query, to clarify a true primary diagnosis.
    This will be even more true with the transition to PDPM where reimbursement will be largely based on the primary diagnosis. Medicare wants to see a clear picture of the patient's condition. They don't want to see symptom codes as this does not justify any skilled services provided to the patient. Instead of weakness, they want to hemiplegia r/t CVA. Instead of difficulty walking, they want to see aftercare r/t hip replacement. We all have to start holding our clinical staff to a higher standard in terms of detailed documentation in order to accurately represent medical necessity for services provided and to maximize reimbursement.

    ------------------------------
    Jacqueline Mccauley
    HIM Director
    ------------------------------



  • 3.  RE: PDPM in LTC - codes that will be rejected 10/1/19

    Posted 14 days ago
    Hi thanks!  Hopefully Coding Clinic addresses this!

    AHIMA needs to update their ICD-10-CM Coding Guidance for LTC

    http://bok.ahima.org/doc?oid=107574

     

    Scenario      

    Principal Diagnosis Description (Index Entry)

    Principal Diagnosis Rationale

    Secondary Diagnosis Description

    Secondary Diagnosis Rationale



    4

    Patient admitted to hospital with generalized weakness, history of recent falls and failure to thrive. Patient admitted to SNF for ongoing PT and OT.

    R53.1 Weakness Weak, weakening, weakness (generalized)

    In ICD-10-CM, there is not a separate code to identify admission to a long-term care facility for physical, occupational, or speech therapy. Coding Clinic 4th Quarter 2012, pages 90-98 state that when a patient is admitted to a long-term care facility for nonspecific reasons rather than a specific diagnosis, it is appropriate to assign codes for the symptoms.

    R62.7 Adult failure to thrive Failure, failed; to thrive; adult
    Z91.81 History of falling
    History; personal (of); fall, falling

    R62.7 RATIONALE: Patient has documented failure to thrive. Z91.81 RATIONALE: Patient has a documented history of falling.



    ------------------------------
    Bill Roush, RHIA, BSHI, AHIMA-Approved ICD-10-CM Trainer
    ------------------------------



  • 4.  RE: PDPM in LTC - codes that will be rejected 10/1/19

    Posted 13 days ago
    I don't think AHIMA or Coding Clinic advice is that you should never use Symptoms (R codes) as a PDX in the LTC setting, but rather as last resort if there is a better choice. In Coding Clinic 4Q 2012 pg 90-98 there are many example scenarios. One question asks "A patient is admitted to a long-term care facility for nonspecific reasons such as generalized weakness, debility, or deterioration (or "old age"), rather than for a specific diagnosis. What is the appropriate principal diagnosis when the patient is admitted for these non specific complaints?" The advice given is "It would be appropriate to assign codes for the symptoms ( i.e., generalized weakness, gait disturbance, debility, etc" A couple of weeks ago, someone posted a question on what PDX would be assigned for a patient coming to Rehab for generalized weakness following a hernia operation.  I advised using Z48.815, Encounter for surgical aftercare following surgery on the digestive system.  However other members were advising to assign Muscle weakness etc. I did not agree as this Coding Clinic has a specific example which I provided of a patient who was admitted for convalescence and strengthening following CABG.  The advice given was to assign Z48.812, Encounter for surgical aftercare following surgery on the circulatory system. Again, I think Symptom codes would be appropriate when there is not a more specific code available.





  • 5.  RE: PDPM in LTC - codes that will be rejected 10/1/19

    Posted 12 days ago
    At times we do get those that are admitted to the SNF for aftercare for therapy and all we have to go on is a symptom code. After reviewing the transfer documentation to see what was found after work up in the acute setting-diligently focusing on a better primary diagnosis, sometimes in the end all we have to support is a symptom code. Of course if we have a symptom code and we find a primary that will support, we will use the aftercare code or a injury code (Fx) or a specific medical diagnosis instead.
    one thing that im pushing at several of my facilities is that HIM has to be involved with this new payment model!!  That's another discussion at another time!
    I am attending many seminars in the upcoming months so it should be interesting. Hope to see a lot of networking on here about this!!

    ------------------------------
    Anissa McBreen RHIT
    Carespring Health Care Management
    Corporate Regional HIM Consultant /Privacy Officer
    HIM LTC Consultant
    Mjmcbreen@aol.com
    ------------------------------



  • 6.  RE: PDPM in LTC - codes that will be rejected 10/1/19

    Posted 11 days ago
    I agree that weakness, debility, gait disturbance, etc are frequent reasons for skilled and LTC admissions.  We are a CAH with skilled beds and frequently have patients's admitted to skilled for PT and OT in order for the patient to gain strength so he/she can return home or to Assisted Living.  I agree weakness, etc. should not be a catch-all diagnosis but is appropriate when it is "the reason, after study, that caused the admission".  Thanks everyone.

    ------------------------------
    Nelda Laskey RHIT
    Coder/RAC Coordinator
    Kearny County Hospital
    ------------------------------



  • 7.  RE: PDPM in LTC - codes that will be rejected 10/1/19

    Posted 11 days ago
    ​I work in Homecare and none of the R codes are going to be acceptable as the primary diagnosis beginning January 1, 2020 per PDGM (Patient Driven Groupings Model).
    Muscle weakness, rheumatoid arthritis or urinary incontinence and pain codes are not going to be acceptable either. Sometimes it's hard to get a more definitive physician diagnoses. We have to query our clinicians for something more descriptive than "unspecified" heath conditions.

    ------------------------------
    Lois Hoyer
    Coding Analyst Lead
    ------------------------------



  • 8.  RE: PDPM in LTC - codes that will be rejected 10/1/19

    Posted 11 days ago

    Are we saying that "some" insurances are not accepting muscle weakness, etc as principal dx or are we saying according to coding conventions (i.e., coding clinic) we cannot use muscle weakness, etc. as principal dx?  There is definitely a difference and I thought I read somewhere recently that Medicaid in Kansas was not accepting the muscle weakness, etc.  But not completely sure.  What is everyone's understanding on this issue and what state are you located in?  Thanks to everyone. 

    Confidentiality Statement: The information transmitted by the following e-mail is intended only for the addressee and may contain confidential and/or privileged material. Any interception, review, retransmission, dissemination, or other use of, or taking of any action upon this information by persons or entities other than the intended recipient is prohibited by law and may subject them to criminal or civil liability. If you received this communication in error, please contact us immediately at (620) 355-7111 please dial 0 for an operator, and delete the communication from your computer or network system. Although this email and any attachments are believed to be free of any virus or other defect that might negatively affect any computer system into which it is received and opened, it is the responsibility of the recipient to ensure that it is virus free and no responsibility is accepted by the sender for any loss or damage arising in any way in the event that such a virus or defect exist.





  • 9.  RE: PDPM in LTC - codes that will be rejected 10/1/19

    Posted 11 days ago
    The discussion is about Medicare not accepting certain symptom codes as PDX once PDPM goes into effect. Coding guidelines do clearly state that it is acceptable to use symptom codes when a more definitive dx is not available. This seems to be an issue with payor policies and official coding guidelines clashing, especially when a definitive dx can be difficult to come by in LTC. I am in Washington state; we haven't historically had any issues with this, but it sounds like PDPM is about to change that.

    ------------------------------
    Jacqueline Mccauley
    HIM Director
    ------------------------------



  • 10.  RE: PDPM in LTC - codes that will be rejected 10/1/19

    Posted 3 days ago
    I certainly hope AHIMA is advocating for us in post-acute care as well as advocating for following the Official Coding Guidelines.  I don't understand why unspecified codes and other non-specific codes (signs/symptoms/abnormal findings, etc.) will be rejected outright instead of just placing them into the default reimbursement category? I further don't understand why CMS is singling out post-acute care with regard to unspecified/non-specific codes?  In my opinion, generalized muscle weakness and some of the other signs/symptoms/abnormal findings are appropriate in certain circumstances.  For example, failure to thrive is a condition we see frequently in post-acute care and there is not always an underlying condition that is causing it. All too frequently I come across patients who were admitted to the hospital with abdominal pain and no underlying cause is ever determined, the pain itself has resolved and there are no other acute conditions other than profound generalized muscle weakness.

    ------------------------------
    Tracey Jenkins
    Health Information Consultant
    Carlin & Associates, LTD.
    ------------------------------



  • 11.  RE: PDPM in LTC - codes that will be rejected 10/1/19

    Posted 2 days ago
    I agree, Tracey. It seems particularly unfair to reject unspecified codes outright for post-acute providers. If the hospital has not done their due diligence in determining underlying conditions, we often do not have the resources in facility to make any further investigation and thus apply more specified codes. The onus should really be on hospitals not to send out patients without sufficient investigation and documentation. So often acute care physicians fail to properly document a patient's chronic conditions which leaves us dealing with major holes in our knowledge of the patient upon admission. This effects both care and coding, and can have a serious detrimental impact in both areas.

    ------------------------------
    Jacqueline Mccauley
    HIM Director
    ------------------------------



  • 12.  RE: PDPM in LTC - codes that will be rejected 10/1/19

    Posted 2 days ago

    Hi, great to see all the PDPM talk!  CMS will reject all Unspecified side of the body codes if reported on MDS as Primary Diagnosis effective 10/1/19.

     

    Unspecified side of the body to me as an auditor means the facility does not know their patient/resident very well ��

     

    My state's MAC said in 2016 they were waiting for CMS directives related to Unspecified codes in LTC so I guess that is finally happening.

     

    -Bill Roush, RHIA, BSHI, AHIMA-Approved ICD-10-CM Trainer