New diagnostic codes apply to long-term care providers
Diagnostic coding can be complicated in hospital settings. It can be even more so in long-term care facilities. Nevertheless, it’s a requirement for your long-term care customers, and with the recent switch to ICD-10-CM coding, it’s more important than ever that they understand the role and importance of these codes and know how to implement them.
As of Oct. 1, 2015, long-term care facilities, along with their hospital and physician counterparts, were required to move from the ICD-9-CM coding system to ICD-10-CM. Much like ICD-9-CM, the new coding system is designed to facilitate the collection and organization of healthcare statistics on the incidence of disease, according to the American Health Information Management Association (AHIMA). Diagnostic coding is used to:
- Collect diagnostic and statistical data about people treated by healthcare providers
- Support clinical decision-making
- Support reimbursement for services provided
- Comply with federal standards for reporting diagnostic data
- Provide data to support clinical research and quality improvement activities
HIPAA requires all providers – including long-term care facilities – to adhere to ICD-10-CM coding, and as such, long-term care administrators must be able to educate their staff who must work with or assign diagnostic codes on the appropriate rules and regulations. To do so requires a working knowledge of the terms and definitions associated with ICD-10-CM coding.
Terms and definitions
Principal diagnosis
Long-term care facilities have varying rules and regulations that require coded data, and at times there may be conflict in the requirements and terminology, notes AHIMA. For instance, the term primary diagnosis is often used to indicate the reason for skilled Medicare services, which may differ from the resident’s reason for continued stay, AHIMA points out. Definitions of principal diagnosis include:
- First-listed diagnosis. This refers to the diagnosis that is sequenced first. Terms such as principal and primary may be used interchangeably to define this.
- Principal diagnosis. This refers to the condition established that is chiefly responsible for the patient’s admission to the hospital. It is always the first-listed diagnosis on the health record and applies to nursing homes as well (as stated in guidelines).
- Primary diagnosis. This indicates the reason for the continued stay in the long-term-care facility and is often used interchangeably with the principal diagnosis.
Principal diagnosis in other regulations
According to the Medicare Program Integrity Manual, the term primary diagnosis refers to the reason for therapy services (also known as the medical diagnosis). The Therapy and Evaluation Plan of Care document for new Medicare Part A stays requires the physician or practitioner to document the medical reason supporting therapy services, according to AHIMA. The diagnosis code representing the medical reason may be identified as primary diagnosis or medical diagnosis on the therapy plan. However, the medical diagnosis may not be the same reason for the continued stay in the facility.
AHIMA provides the following example of the above scenario: A patient with Parkinson’s disease returns after a hospitalization for pneumonia to start a new Medicare Part A stay. Pneumonia is identified as the medical diagnosis on the therapy evaluation and plan of care to support the skilled therapy services, along with the appropriate therapy treatment diagnoses. However, Parkinson’s disease is the reason for the continued facility stay and continues to be sequenced first on the record and the UB-04. The reason for the new focus of care and Medicare Part A stay (i.e., pneumonia) is sequenced second.
The use of Z codes in long-term care facilities
Assigning V codes in ICD-9-CM was known to cause confusion and controversy in long-term care facilities. Many facilities were told not to assign V codes as the principal diagnosis, or even at all, according to AHIMA. Z codes in ICD-10-CM are synonymous with V codes in ICD-9-CM. The established ICD-10-CM code and the official guidelines provide specific instruction and guidance to both the coder and billing staff for appropriate use of Z codes in long-term care facilities.
In long-term care, one of the most common reasons for initial admission is rehabilitation, such as physical, occupational and speech-language therapy, notes AHIMA. Unlike ICD-9-CM, there is no equivalent code in ICD-10-CM for admission for, encounter for, or care involving rehabilitation procedures. According to Coding Clinic, patients admitted to a long-term care facility specifically for rehab following an injury should be assigned the acute injury code. When a patient is being treated at the hospital for an acute medical condition and is subsequently admitted to long-term care for rehab, the acute condition should be coded as the first listed/principal diagnosis, followed by any chronic conditions that will be treated at the skilled nursing facility.
Z codes are often assigned for aftercare following surgical procedures performed in the hospital for which the patient is sent to the long-term care facility to recover. However, aftercare Z codes are not used for aftercare following injuries or fractures.
Continued treatment of acute care conditions
Acute conditions treated at the hospital that continue to require follow-up or ongoing monitoring should be coded with an acute diagnosis code, as long as the condition persists and requires follow-up. Codes for the acute medical condition treated and resolved in the hospital are assigned and reported by the hospital, but not coded or reported by the long-term care facility. The long-term care facility reports Z codes to identify the provision of aftercare.
Diagnosis List and UB-04 Claim Form
Residents in long-term care facilities often have numerous chronic conditions. The diagnosis list is a comprehensive listing of these conditions, which are often sequenced in order of focus and complexity of care for the resident, according to AHIMA. The number of diagnoses listed can be extensive and may exceed current reporting capacity with the implementation of the UB-04 (Universal Billing Form, version 5010) on Jan. 1, 2012, which only allows for 25 codes.
Prior to submission of the UB-04 claim, facilities must validate that the ICD-10-CM diagnoses reported on the claim are consistent with the health record documentation and MDS information. This is commonly referred to as a triple-check process, notes AHIMA. Reporting ICD-10-CM diagnosis codes supported by health record documentation and the MDS will support the claim submitted for therapy services. The facility’s reimbursement is determined by the Resource Utilization Group (RUG) category based on the MDS assessment data. The triple-check process ensures that the diagnosis data submitted for each payment mechanism is consistent.
Medicare Part B therapy services
The medical diagnosis that identifies the reason for the Part B therapy services should be listed on the MDS after the reason for the continued stay. Other ICD-10-CM codes for chronic conditions that affect the resident’s progress may also be reported to support therapy services. In addition, ICD-10-CM codes representing the medical condition that required the treatment are used when there is no code representing the treatment.
A working knowledge of ICD-10-CM coding guidelines is particularly important as long-term care facilities prepare for inspections. In its Compliance Program Guidance for Nursing Facilities, the Office of Inspector General recommends that nursing facilities take all reasonable steps to ensure compliance with federal healthcare programs when submitting information that determines reimbursement decisions. Ensuring accurate information requires ongoing training and evaluation of the staff responsible for coding diagnoses, as well as regular internal audits of coding policies and procedures, AHIMA advises. Accurate coded data will continue to play an important role in the long-term care industry, it adds.
Editor’s note: For more information, AHIMA recommends the “ICD-10-CM Official Guidelines for Coding and Reporting,” which is the companion document to the official version of ICM-10-CM published on the National Center for Health Statistics website.