The buzz around the proposed rule for fiscal 2023 continues as providers aim to review, digest and comment on proposed updates to the SNF payment rates, wage index adjustments, methodology for recalibrating PDPM parity adjustment, quality reporting and value-based purchasing updates, and multiple requests for information (RFIs).
Of equal interest, we see proposed updates to ICD-10 mappings, which are aimed at more effectively reflecting clinical accuracy for the patients we serve daily.
The Centers for Medicare & Medicaid Services is proposing several changes to the PDPM ICD-10 code mappings and lists.
CMS notes that, in the case of any diagnoses that are either currently mapped to “Return to Provider” or that we are proposing to classify into this category, this is not intended to reflect any judgment on the importance of recognizing and treating these conditions, but merely that there are more specific diagnoses than those mapped to “Return to Provider” or that we do not believe that the diagnosis should serve as the primary diagnosis for a Part A covered SNF stay.
Sound familiar? As we all know, when assessing ICD-10 code structure we should as a rehab team aim to code to the highest level of specificity. This not only helps to support our unique skills but furthermore allows us to identify more granular needs in those we serve.
Therapists take note: Understanding these changes will impact coding accuracy in the new fiscal year.
Let’s review the proposals together.
D75.839 “Thrombocytosis”— Proposed change from “Cardiovascular and Coagulations” to “Return to Provider”
Reason: Oct. 1, 2021, D75.839 “Thrombocytosis, unspecified,” took effect and was mapped to the clinical category of “Cardiovascular and Coagulations.”
However, CMS notes there are more specific codes to indicate why a patient with thrombocytosis would require SNF care.
If the cause is unknown, the SNF could use D47.3, “Essential (hemorrhagic) thrombocythemia” or D75.838, “other thrombocytosis,” which is a new code that took effect Oct. 1, 2021.
Additionally, elevated platelet count without other symptoms is not reason enough for SNF care, so this would not be used as a primary diagnosis. For this reason, CMS proposes to change the assignment of D75.839 to “Return to Provider.”
F32.A, “Depression, unspecified” — Proposed change from “Medical Management” to “Return to Provider”
Reason: On Oct. 1, 2021, F32.A, “Depression, unspecified” went into effect and was mapped to “Medical Management.”
However, there are more specific codes that would more adequately capture the diagnosis of depression.
Further, while CMS believes that SNFs serve an important role in providing services to those beneficiaries suffering from mental illness, the SNF setting is not the setting that would be most appropriate to treat a patient whose primary diagnosis is depression.
For this reason, they propose to change the assignment of F32.A to “Return to Provider.”
D89.44, “Hereditary alpha tryptasemia” — Proposed change from “Medical Management” to “Return to Provider”
Reason: On Oct. 1, 2021, D89.44, “Hereditary alpha tryptasemia,” went into effect and was mapped to the clinical category, “Medical Management.”
However, CMS notes this is not a diagnosis that would be treated as a primary condition in the SNF, rather it would be treated in the outpatient setting.
Therefore, CMS proposes to change the assignment of D89.44 to “Return to Provider.”
G92.9, “Unspecified toxic encephalopathy” — Proposed change from “Acute Neurologic” to “Return to Provider”
Reason: On Oct. 1, 2021, G92.9, “Unspecified toxic encephalopathy,” took effect and was mapped to the clinical category of “Acute Neurologic.”
However, CMS notes there are more specific codes that should be used to describe encephalopathy treated in a SNF.
Therefore, CMS proposes to change the assignment of G92.9 to “Return to Provider.”
M54.50, “Low back pain, unspecified”— Proposed change from “Non-surgical Orthopedic/Musculoskeletal” to “Return to Provider”
Reason: On Oct. 1, 2021, M54.50, “Low back pain, unspecified,” went into effect and was mapped to the clinical category of “Non-surgical Orthopedic/Musculoskeletal.”
However, if low back pain were the primary diagnosis, the SNF should have a greater understanding of what is causing the pain.
There are more specific codes to address this condition. Therefore, CMS proposes to change the assignment of M54.50 to “Return to Provider.”
Esophageal Based Codes — Shift to Medical Management
K22.11, “Ulcer of esophagus with bleeding;” K25.0, “Acute gastric ulcer with hemorrhage;” K25.1, “Acute gastric ulcer with perforation;” K25.2, “Acute gastric ulcer with both hemorrhage and perforation;” K26.0, “Acute duodenal ulcer with hemorrhage;” K26.1, “Acute duodenal ulcer with perforation;” K26.2, “Acute duodenal ulcer with both hemorrhage and perforation;” K27.0 “Acute peptic ulcer, site unspecified with hemorrhage;” K27.1, “Acute peptic ulcer, site unspecified with perforation;” K27.2, “Acute peptic ulcer, site unspecified with both hemorrhage and perforation;” K28.0, “Acute gastrojejunal ulcer with hemorrhage;” K28.1, “Acute gastrojejunal ulcer with perforation;” K28.2, “Acute gastrojejunal ulcer with both hemorrhage and perforation;” and K29.01, “Acute gastritis with bleeding.”
Reason: Upon review of these codes, CMS recognizes that they represent conditions with more specificity than originally considered because of the bleeding (or perforation) that is part of the conditions and that they would more likely be found in SNF patients.
Therefore, CMS proposes all move to “Medical Management.”
Generalized Muscle Weakness
CMS notes they also received a comment requesting we consider remapping M62.81, “Muscle weakness (generalized)” from “Return to Provider” to “Non-orthopedic Surgery” with the rationale that there is currently no sequela or late-effects ICD-10 code available when patients require skilled nursing and therapy due to late effects of resolved infections such as pneumonia or urinary tract infections.
CMS considered the request and determined that muscle weakness (generalized) is nonspecific and if the original condition is resolved, but the resulting muscle weakness persists as a result of the known original diagnosis, there are more specific codes that exist that would account for why the muscle weakness is on-going, such as muscle wasting or atrophy.
Therefore, CMS is not proposing this specific remapping.
In closing, changes are coming. Take note!
These are some positive steps to ensuring care and reimbursement align with patient needs, evidence-based practice and the unique level of skilled care you provide daily.
Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at [email protected].
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
