Can I use M codes as primary diagnosis?



M codes can be used as long as they are not “return to provider” codes. Recommend utilizing the CMS ICD-10 Mapping Tool listed under the resources below to determine if diagnosis can be considered as primary.

According to the Medicare Benefit Policy Manual, Chapter 8, the beneficiary must require SNF care for a condition that was treated during the qualifying hospital stay, or for a condition that arose while in the SNF for treatment of a condition for which the beneficiary was previously treated in the hospital. In this context, the applicable hospital condition need not have been the principal diagnosis that actually precipitated the beneficiary’s admission to the hospital, but could be any one of the conditions present during the qualifying hospital stay.

The diagnosis requires 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.

Active diagnoses are diagnoses that have a direct relationship to the resident’s current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. For further clarification regarding active diagnosis, please see RAI Manual pp. I-7 through I-15.

The following are other resources that should be helpful:

Blog by Kristen Walden, MSN, RN, RAC-CT, Proactive Medical Review

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