Primary Diagnosis Selection - Why it's Tricky and How to Choose the Right One

PDPM brought many changes in the way we manage our skilled residents. One elusive question is I0020B - the Primary Diagnosis - it not only places the resident into a clinical category that affects payment, but helps set treatment plans and care plans. So what is the best way to select the most appropriate diagnosis? Read on to learn some tips for mastering this important task.

One thing that successful SNFs do to manage PDPM is meet daily to discuss skilled residents. Part of this process is having the team come prepared to discuss areas of the resident's care that are most important from their department's perspective. From there, the MDS nurse can determine the most pertinent reason the resident is in the SNF for skilled care and subsequently which diagnosis will place the resident in the most appropriate clinical category. Admittedly, this does take a little bit of time, but it is time well-spent considering the clinical and financial implications of selecting an inappropriate diagnosis. The process should look something like this:

• Team reviews hospital records and discharge summary prior to meeting

• List the diagnoses and care items that require skilled care in a SNF setting

• Discuss the goals and needs for successful discharge from skilled care

• Cross reference each diagnosis to determine the clinical category

• Select the most appropriate diagnosis with confidence and ease

Once you have your diagnosis selected, MDS coding conventions must be utilized. One common mistake I see quite frequently is using an acute diagnosis. The RAI manual specifies, "While certain conditions listed in I0020 represent acute diagnoses, SNFs should not use acute diagnoses in I0020B. Sequelae and other such codes should be used instead". To avoid this mistake do not copy ICD-10 codes from hospital paperwork. Instead, ask yourself, are we actively treating this diagnosis? Or are we treating something that was caused by the diagnosis. See that examples below for more clarification.

As you review the following examples, ask yourself the above questions to determine the appropriate coding.

Examples of Common Coding Errors

• Listing CVA as primary instead of using sequelae diagnosis

Resident was treated in the hospital for Cerebral Infarction due to Thrombosis of right vertebral artery. Upon discharge from the hospital she has noted hemiplegia.

The most appropriate diagnosis is going to be related to hemiplegia since the CVA is no longer active and the SNF is treating the hemiplegia.

• Not listing the required additional ICD-10 code to support the Z-code

Resident had an elective surgery to replace the left knee joint. She requires assistance to walk and use the bathroom upon discharge from the hospital.

Since the SNF did not perform the knee replacement we should not use the ICD-10 code for the knee replacement as primary, instead we are skilling this resident for the Aftercare of a Joint Replacement (Z47.1). In addition, the ICD-10 Manual gives further guidance that an additional code is required in order to specify the joint.

• Listing a joint replacement instead of the causative fracture

Resident fell and suffered a right hip fracture. He had to have the hip replaced. He cannot walk and requires extensive assistance to perform his daily routine.

In this scenario, we are still treating the aftercare of the fracture and hip replacement, however, the ICD-10 manual guides us as follows: For rehabilitation services following a total hip replacement due to a fracture, since this fracture is now considered to be in the healing and recovery phase, assign first the appropriate injury code from category S72 with the 7th character of subsequent ensounter followed by the presence of artificial hip joint.

• As you can see, utilizing the ICD-10 manual is critical for selecting and sequencing diagnoses correctly! If you or your staff are using Google or a cheat sheet to look up ICD-10 codes there will be many mistakes coded.

• Listing a diagnosis that has already been resolved (i.e. sepsis)

Resident was admitted to the hospital with delirium and is diagnosed with urosepsis. She is treated with antibiotics and and the delirium has resolved. The discharging doctor resolves the sepsis diagnosis and sends her to your SNF with orders to continue IV antibiotics for 5 more days.

In this case, you cannot code sepsis because the hospitalist documented it as resolved. It would be most appropriate to call the physician accepting this patient at your SNF and ask him for a diagnosis of sepsis in order to code this item. Be sure he is aware of any signs, symptoms and medications that the resident has in order for him/her to make the correct decision.

CMS has posted a lookup file of updated FY2022 codes and their corresponding clinical categories on their website (bottom of page if you click the link). Although your software maps this for you, on occasion there could be an error and you can check it here. If you save this file to your computer you will have access to it in the event that your internet is down or if you don't have access to your MDS software.

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