PDPM coding and reimbursement success relies significantly on ICD-10 coding accuracy. In particular, the impact of ICD.10 coding on the clinical category, SLP, Nursing, and NTA comorbid diagnoses cannot be overstated; Medicare reimbursement for SNF services depends on accurate coding. Unfortunately, diagnosis coding is not a skill easily mastered on the job. In fact, the ICD-10-CM coding manual itself can be cumbersome and difficult to understand with multiple coding options based on specificity, not to mention the additional instruction found in the ICD-10-CM Official Guidelines for Coding and Reporting. In this week’s blog, we’ll take a closer look at common ICD-10-CM coding errors we find in SNF documentation and how to overcome them.

Common ICD-10-CM Coding Errors

  1. Primary reason for skilling diagnosis (I0020B) is not effectively supported in the documentation. Avoiding the error:
      • Implement a team meeting to determine what is driving the care plan. The interdisciplinary team should discuss the patient’s conditions, comorbidities, and information from the hospital stay, along with a review of physician documentation.
      • When there are 2 or more diagnoses that could qualify as the primary diagnosis for a resident, document the diagnosis considered as primary and the team’s clinical decision making for choosing the diagnosis to be coded in I0020B.

  1. The diagnosis was resolved in the acute setting. Avoiding the error:
      • Ensure the team completes a thorough review of the hospital records.
      • Understand instruction from the FY 2019 SNF PPS Final Rule: “CMS recognizes that in many cases, the primary reason for SNF care may not be exactly the same as the primary reason for the prior inpatient stay. For example, a beneficiary may be treated in a SNF for a secondary condition that arose during the prior inpatient stay but that is different from the condition that precipitated the acute inpatient stay. PDPM requires facilities to code the diagnosis that corresponds most closely to the primary reason for SNF care rather than the primary reason for the prior hospitalization.”

  1. Accurate coding of surgical procedure during the hospital stay. Avoiding the error:
      • Code surgeries that are documented to have occurred in the last 30 days, and during the inpatient stay that immediately preceded the resident’s Part A admission, that have a direct relationship to the resident’s primary SNF diagnosis, as coded in I0020B.
      • Take note of examples of the surgeries that are included for each surgical category (J2300-J5000).
      • The RAI also includes multiple case examples of surgeries with appropriate coding and rationale (RAI pg. J-47 – J-49).

  1. Appropriate coding for fractures using correct 7th character and following surgical intervention. Avoiding the error:
      • According to the ICD-10-CM Official Guidelines, coding an aftercare Z code for injuries such as fractures is prohibited. On pg. 76, the guidelines state, “The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter).”
      • Note that 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.

  1. The diagnosis is not supported by the physician or physician extender. Avoiding the error:
      • ICD-10-CM coding requires consistent and complete documentation from the provider (physician/nonphysician practitioner) to support all aspects and specific details of the diagnosis.
      • Ensure a thorough record review to include, but not limited to the most recent history and physical, transfer documents, discharge summaries, progress notes, diagnosis / problem lists, and other resources as available.
      • The disease conditions in MDS section I require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days.
      • Centers for Medicare & Medicaid Services’ (CMS) presentation ICD-10 and Clinical Documentation presented by Dr. Joseph Nichols is a helpful tool that describes the necessary provider-supplied documentation that supports ICD-10-CM coding in the long-term care (LTC) setting.

  1. Inaccurately coding MDS I4500 (cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke) related to past medical history. Avoiding the error:
      • If the previous CVA has no residual effectives, the diagnosis is not active.
      • Medication given as a preventative measure is not indicative of an active diagnosis.
      • Residual effects, such as hemiplegia, dysphagia, aphasia, etc., should be reported in the appropriate check box (I4900 hemiplegia or hemiparesis), or I8000 using the appropriate ICD-10-CM code.

  1. Coding acute (I60-I67) CVA codes instead of the sequela codes (I69). Avoiding the error:
      • On pg. 51 of the coding guidelines, it states, “Category I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of sequela (neurologic deficits), themselves classified elsewhere. These “late effects” include neurologic deficits that persist after initial onset of conditions classifiable to categories I60-I67.”
      • Acute CVA codes are not to be used in the SNF. According to the RAI, pg. 1-2, “When an acute condition represents the primary reason for the resident’s SNF stay, it can be coded in I0020B. However, it is more common that a resident presents to the SNF for care related to an after effect of a disease, condition, or injury. Therefore, subsequent encounter or sequelae codes should be used.”
  1. No physician query process. Avoiding the error:
      • Implement a physician query process early in the skilled stay to add a new diagnosis or to clarify an existing diagnosis for greater specificity.
      • Physician queries should not lead the provider towards a specific diagnosis.
      • Develop templates for common requests.


Other tips to avoid ICD-10-CM coding errors

      • Do not copy diagnoses from the hospital records. Ensure a process for the thorough review of the admission/transfer documentation to correctly assign codes. Query the physician when necessary.
      • Train more than one person to serve as the expert coder in your facility. Offer coding refresher education to include ICD-10 annual updates at least annually, at a minimum.

Join Proactive’s upcoming workshop on March 5th, Virtual ICD-10 CM Coding Refresher for Skilled Nursing Facilities, for more expert coding tips and updates, including best practice for accurate ICD-10-CM code assignment, how to avoid common mistakes, and the importance of principal diagnosis identification.




Stacy Baker, OTR/L, CHC, RAC-CT
Director of Audit Services

Was this article helpful? Access weekly insights when you sign up for our weekly newsletter!