The landscape of coding within post-acute care has undergone a significant evolution, particularly in recent years. For coding professionals, this shift presents an exciting frontier to leverage our specialized skills. For those immersed in the post-acute care environment, such as skilled nursing facilities (SNFs), it signifies a critical adaptation to new methodologies.
Prior to October 1, 2019, reimbursement for post-acute care facilities was structured around the Resource Utilization Group (RUG) system. Coders are familiar with the concept of grouping, and RUGs were determined by the resident’s service needs. In essence, a higher need for skilled services correlated with a higher RUG classification, which in turn led to greater reimbursement.
However, October 2019 marked the implementation of the Patient-Driven Payment Model (PDPM), a paradigm shift from the RUG system. PDPM moved away from a single RUG classification and instead categorizes residents into five distinct case-mix adjusted components: Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP), Non-Therapy Ancillary (NTA), and Nursing. This represented a substantial change from the RUG-IV model, where a single group determined case-mix indices and per diem rates across all components. Under PDPM, each resident receives a separate classification for each of these five components.
Each of these components carries its own case-mix index and per diem rate. Furthermore, PDPM incorporates variable per diem adjustments for PT, OT, and NTA components to reflect the changing resource utilization throughout a resident’s stay. While the complete per diem rate calculation involves additional factors, this provides a fundamental understanding of PDPM’s structure.
The selection of a primary diagnosis has become paramount under PDPM, mirroring the importance of the principal diagnosis in inpatient coding. This primary diagnosis plays a crucial role in mapping the resident into one of ten clinical categories: Acute Infection, Acute Neurologic, Cancer, Cardiovascular and Coagulations, Major Joint Replacement or Spinal Surgery, Medical Management, Non-Orthopedic Surgery, Non-Surgical Orthopedic/Musculoskeletal, Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery), and Pulmonary.
These clinical categories share conceptual similarities with MS-DRGs. In the MS-DRG system, we recognize certain conditions as complications or comorbidities (CCs) or major CCs (MCCs). In the post-acute care setting, secondary or additional diagnoses that are actively managed or monitored are also assigned. Some of these conditions may be designated as an SLP comorbidity or an NTA comorbidity, impacting the respective component classifications and ultimately, reimbursement.
Comprehensive and timely documentation is indispensable for accurate and thorough coding in post-acute care. Moreover, documentation must be appropriately authenticated to serve as valid coding support. Long-term care facilities must rigorously review incoming documentation upon admission or transfer, focusing not only on completeness but also on proper authentication. While long-term care facilities do not assign ICD-10-PCS codes, they must ensure that operative reports, when relevant, are included in the transfer documentation. This review is crucial for the accurate completion of their data sets.
Long-term care facilities utilize the Outcome and Assessment Information Set (OASIS), a standardized data set developed by the Centers for Medicare & Medicaid Services (CMS). Meticulous review of the OASIS form is essential to verify that the collected data accurately reflects the resident’s condition and supports the assigned codes.
Crucially, all long-term care facilities are mandated to assign ICD-10-CM codes. This necessitates adherence to the Official Guidelines for Coding and Reporting. As credentialed and certified coding professionals, we possess an in-depth understanding of these guidelines. This expertise becomes increasingly valuable in the post-acute care setting.
This evolving landscape in post-acute care offers a significant opportunity for coding professionals to provide invaluable guidance and support to a sector where coding accuracy and expertise have reached unprecedented importance. Understanding coding principles, including concepts related to comorbidities and complications often discussed in the context of CCS, enhances a coder’s ability to navigate the complexities of PDPM and contribute to accurate reimbursement in post-acute care.
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