On September 18, 2019, CMS published the updated Resident Assessment Instrument (RAI) Manual V1.17.1 replacement manual pages and change tables. In order to assist providers with accurate clinical category designation under the Patient Driven Payment Model (PDPM), CMS provided clarification for Section I (Active Diagnoses) regarding how to code the primary reason for the SNF admission, I0020B, as well as I8000.

I0020 denotes the resident’s default primary diagnosis clinical category for Physical Therapy (PT), Occupational Therapy (OT), and Speech Language Pathology (SLP) PDPM components.  I0020B denotes the primary reason for the SNF admission. In other words, the primary medical condition that requires care in the SNF.

 

In the RAI manual, under ‘Steps for Assessment’ on page I-1 in Chapter 3, CMS states, “Indicate the resident’s primary medical condition category that best describes the primary reason for the Medicare Part A stay”. Under the ‘Coding Instructions’ on page I-2, Chapter 3, CMS states, “Indicate the resident’s primary medical condition category that best describes the primary reason for the Medicare Part A stay; then proceed to I0020B and enter the International Classification of Diseases (ICD) code for that condition, including the decimal”. And a new bullet point which states, “While certain conditions described below represent acute diagnoses, SNFs should not use acute diagnosis codes in I0020B. Sequelae and other such codes should be used instead”.

We must not forget that the primary clinical category may change depending as to whether or not the resident had a major surgery that occurred during the preceding qualifying hospital stay in Section J items J2100-5000.

In the Primary Medical Condition examples on I-3 and I-4 in Chapter 3, CMS provides insight regarding acute coding.

Examples of Primary Medical Condition

Example 1: Ms. K is a 67-year-old female with a history of Alzheimer’s dementia and diabetes who is admitted after a stroke. The diagnosis of stroke, as well as the history of Alzheimer’s dementia and diabetes, is documented in Ms. K’s history and physical by the admitting physician.

Coding: I0020 would be coded 01, Stroke. I0020B would be coded as I69.051 (Hemiplegia and hemiparesis following non-traumatic subarachnoid hemorrhage).

Rationale: The physician’s history and physical documents the diagnosis stroke as the reason for Ms. K’s admission. The ICD-10 code provided in I0020B above is only an example of an appropriate code for this condition category.

Example 2: Mrs. H is a 78-year-old female with a history of hypertension and a hip replacement 2 years ago. She was admitted to an extended hospitalization for idiopathic pancreatitis. She had a central line placed during the hospitalization so she could receive TPN (total parenteral nutrition). She also received regular blood glucose monitoring and treatment with insulin when she became hyperglycemic. During her SNF stay, she is being transitioned from being NPO (nothing by mouth) and receiving her nutrition parenterally to being able to tolerate oral nutrition. The hospital discharge diagnoses of idiopathic pancreatitis, hypertension, and malnutrition were incorporated into Mrs. H’s SNF medical record.

Coding: I0020 would be coded 13, Medically Complex Conditions. I0020B would be coded as K85.00 (Idiopathic acute pancreatitis without necrosis or infection).

Rationale: Mrs. H had hospital care for pancreatitis immediately prior to her SNF stay. Her principal diagnosis of pancreatitis was included in the summary from the hospital. The surgical placement of her central line does not change her care to a surgical category because it is not considered to be a major surgery. The ICD-10 code provided in I0020B above is only an example of an appropriate code for this condition category.

The ICD-10 codes entered in I8000 provides more clinical information to determine if the resident qualifies for certain comorbidities under the SLP component and the Non-Therapy Ancillaries (NTA).

Even though you would not capture the acute ICD-10 code in I0020B, you could still capture it in I0100-I8000. SNFs will treat the late effects (subsequent encounter) or sequelae caused by the acute condition. In the stroke example above, the resident was treated for the acute stroke in the hospital perhaps with medication or maybe even surgery. In the SNF setting,  we treat the after-effects of a condition and not typically the acute condition. However, there are appropriate acute conditions that can be treated in the SNF and coded in I0020B or I8000.  A great example is pneumonia.  If the resident has acute pneumonia and is receiving active treatment, (antibiotics, oxygen, etc.) for pneumonia, then the pneumonia could be the primary reason for the SNF admission code in I0020B.

Gina Tomcsik
Director of Compliance and Regulatory Strategy