Coding, Classification & Reimbursement

Skilled Nursing and PCS coding

  • 1.  Skilled Nursing and PCS coding

    Posted 05-02-2018 16:35
    Hi, I am trying to get my mind around how LTC facilities will potentially submit PCS codes on the MDS effective October 1, 2019.

    LTC has not used PCS codes and it seems odd to require LTC to locate and submit a PCS code for services provided elsewhere!  

    From the Federal Register:

    "The MDS item I0020 would require facilities to select a primary diagnosis from a pre-populated list of primary
    diagnoses representing the most common types of beneficiaries treated in a SNF, while item
    I8000, if used to assign residents to clinical categories, would require facilities to code a specific
    ICD-10-CM code that corresponds to the primary reason for the resident's Part A SNF stay. As
    indicated above, we are also proposing that providers would code a specific ICD-10-PCS code in
    the second line of item I8000 when surgical information from the prior inpatient stay is
    necessary to assign a resident to a clinical category."

    As far as day of transfer to SNF from acute hospital, is the PCS code already assigned (and could be shared with SNF) or does PCS code assignment typically take a few days post discharge from acute hospital?

    If you want to comment back to CMS (by June 26th) that this new requirement will increase burden on SNFs (either in training on PCS for LTC, or time spent trying to get the PCS code from the acute hospital), please submit your comments back to CMS (instructions below came from above Federal Register):

    Comments, including mass comment submissions, must be submitted in one of the
    following three ways (please choose only one of the ways listed):

    1. Electronically. You may submit electronic comments on this regulation to Follow the "Submit a comment" instructions.

    2. By regular mail. You may mail written comments to the following address ONLY:
    Centers for Medicare & Medicaid Services,
    Department of Health and Human Services,
    Attention: CMS-1696-P,
    P.O. Box 8016,
    Baltimore, MD 21244-8016.

    Please allow sufficient time for mailed comments to be received before the close of the
    comment period.

    3. By express or overnight mail. You may send written comments to the following
    address ONLY:

    Centers for Medicare & Medicaid Services,
    Department of Health and Human Services,
    Attention: CMS-1696-P,
    Mail Stop C4-26-05,
    7500 Security Boulevard,
    Baltimore, MD 21244-1850

    Bill Roush, RHIT, AHIMA-Approved ICD-10-CM Trainer

  • 2.  RE: Skilled Nursing and PCS coding

    Posted 05-02-2018 18:18

    What about the aftercare codes we currently use...seems to me those explain the care LTC facilities are providing the resident, rather than procedure codes. 


  • 3.  RE: Skilled Nursing and PCS coding

    Posted 05-02-2018 18:53
    Yes the Aftercare Z codes are perfect for LTC, seems like CMS is trying to slip PCS into LTC and that will be a rather gigantic change!

    Bill Roush, RHIT, AHIMA-Approved ICD-10-CM Trainer

  • 4.  RE: Skilled Nursing and PCS coding

    Posted 05-03-2018 11:05
    Thanks for the heads-up William.  I surmise only hospitals with CDI practioners and/or perform concurrent coding will have the PCS code available prior to/at discharge.  This will indeed be an administrative burden on hospital staff.  I could also anticipate errors if CDI/coding staff are asked to perform precipitously, as it's use is not hospital based.

    Sheila Goethel
    Coding Services Senior Manager

  • 5.  RE: Skilled Nursing and PCS coding

    Posted 05-08-2018 19:57
    Hi, it looks like the American Association of Nurse Assessment Coordination (AANAC) - the MDS Nurse's Association - is commenting

    back to CMS that there are definite burdens for LTC if they are mandated to use PCS codes on the MDS starting October 1, 2019.

    Some of the burdens that I can see being placed on LTC are:

    $120 for a PCS code book per building (assuming they are not told by their company to "just google the PCS code")

    Time spent per MDS locating the correct PCS code based on Operative Report (would this be 15 minutes per MDS roughly?).

    Training time for SNF HIM and MDS in  the current commonly used PCS codes (during the Acute stay) for the LTC resident.

    If SNFs elect to NOT use a PCS code book and rather choose to chase down the exact PCS code used in Acute, this will involve staff time

    both in the SNF and in the ROI department for the Acute.  This could conceivably delay timely completion of the MDS.

    I work as a Consultant in California, there are roughly 1,100 SNF buildings.  California eliminated the requirement for SNF HIM to hold

    AHIMA credentials (or have access to a Consultant) in the mid 90's (it was slashed from Title 22 for some reason).

    So we have mostly non-credentialed coders in the California SNFs!

    Bill Roush, RHIT, AHIMA-Approved ICD-10-CM Trainer

  • 6.  RE: Skilled Nursing and PCS coding

    Posted 06-28-2018 12:12
    Woohoo!  AHIMA has commented back to CMS:

    "AHIMA opposes CMS' proposal to require SNFs to assign a specific ICD-10-PCS code when surgical information from the prior inpatient stay is necessary to assign a resident to a clinical category. Although the Minimum Data Set (MDS) is not technically covered under the Health Insurance Portability and Accountability Act (HIPAA) regulations, the intent of the HIPAA regulations adopting ICD-10-PCS as a standard code set was that this code set would only be used by hospitals for reporting acute care inpatient services.

    Due to the level of detail and specificity in the ICD-10-PCS coding system, and the lack of nonspecific or general codes, ICD-10-PCS codes cannot be assigned without a complete operative report, which the SNF may not have access to. Even with an operative report, assigning an appropriate ICD-10-PCS code often requires querying the surgeon for additional information. Lack of access to complete medical record documentation and the surgeon who performed the procedure would make it impossible for the SNF personnel to assign the appropriate ICD-10-PCS code. It is not possible to simply select a "general" ICD-10-PCS code, or a code that is "close enough."

    Aside from the barriers presented by lack of access to hospital operative reports and the surgeon, assignment of ICD-10-PCS codes in SNFs would be costly and administratively burdensome. ICD-10-PCS is a complex coding system, requiring extensive formal education. SNF personnel have likely not received ICD-10-PCS coding education, and the cost of ICD-10-PCS training for this limited use of these codes would be prohibitive. Even educated, experienced ICD-10-PCS coding professionals often find the coding system challenging. Determining the appropriate codes can be time consuming, which would adversely impact SNF staff productivity.

    For the reasons stated above, AHIMA does not believe it is feasible or appropriate to require SNFs to report ICD-10-PCS codes.

    We support the alternative approach mentioned in the proposed rule, which would involve the use of item I0020 on the MDS 3.0 as the basis for resident classification into one of the ten clinical categories, since this approach would avoid the need to record additional information on inpatient surgical procedures."

    Read AHIMA's full letter here:

    Unfortunately CMS ignored AHIMA's October 2015 letter requesting that AHIMA credentials (or access to credentialed consultants) be added back into Federal Regulations for HIM in LTC, you can read that letter here: 

    For states (like California) that don't have laws requiring AHIMA credentials (or access to consultants) for LTC HIM, it is fairly absurd to think that a non-credentialed coder could just learn PCS easily (or "Google the PCS codes")!  Add to that, our MAC appears to still not be applying edits to LTC claims that would identify "junk coding" that breaks Guidelines.  The last time I contacted our MAC and they verified no edits on coding for LTC claims, they said they were waiting further instructions from CMS new leadership and the new Presidential administration.  I have not heard President Trump mention ICD-10 yet.  President Obama mentioned "the importance of medical coding" at one point when not getting paid to implement ICD-10 was a gigantic political issue with the AMA.

    Hopefully CMS listens to AHIMA's expert opinion regarding LTC this time!

    If you are wanting specific examples of edits (based on Guidelines) that should be applied to LTC claims (this is also a good list to have handy during Triple Check):

    A code from subcategory R65.2 can never be assigned as a principal diagnosis.

    Codes for underdosing should never be assigned as principal or first-listed codes.

    An external cause code can never be a principal (first-listed) diagnosis.

    Sequela (Late Effects)

    Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.

    Bill Roush comment: A Principal that ends with seventh character S breaks this Guideline!

    For rehabilitation services following active treatment of an injury, assign the injury code with the appropriate seventh character for subsequent encounter as the first-listed or principal diagnosis.

    7th character "A", initial encounter is used for each encounter where the patient is receiving active treatment for the condition.
    7th character "D" subsequent encounter is used for encounters after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.

    Bill Roush comment: using seventh character for initial encounter for LTC stay breaks this Guideline!

    And then there is also the specific directions in Coding Clinic 4th Quarter 2012 "Long Term Care Coding Issues"!  My MAC had never heard of them the last time I checked!

    Bill Roush, RHIT, AHIMA-Approved ICD-10-CM Trainer