Wiki SNF primary dx selection

[jtrong]

Hello -

I am having a hard time determining an appropriate primary diagnosis for a new admission for short term rehab to a SNF.

Patient presented to ER after being found down after an indeterminant amount of time. She was found to have had a small, suspected cardioembolic, stroke with encephalopathy. During her stay at the hospital, her encephalopathy was constantly noted as "improving", "self-resolving", and "stably resolved". She had continuous EEG monitoring which ruled out seizure activity. She was being worked up for paroxysmal atrial fibrillation and discharged with a halter monitor.

In her discharge summary from the hospital, there is no mention of the a-fib but they do note the 30 day halter monitor. The discharge summary also states "discharge diagnosis: encephalopathy in the setting of stroke" but goes on to note that "mental status improved; self-resolving encephalopathy".

Once she arrived at the nursing home, the NP's admitting note states "s/p idiopathic encephalopathy; generalized weakness; felt multi-factorial, probably metabolic in nature".

Of note, her other dxs included: CAD; Weakness; trouble ambulating; previous CVA with right upper extremity weakness; HLD; depression; anxiety. None of these other issues were addressed during her inpatient admission, except for maintenance meds.

Based on the fact that the encephalopathy was indicated to be resolved, self-resolving, etc., I selected the paroxysmal a-fib as primary (because of the halter monitor and the thought that it could have contributed to the stroke) and the guidelines stating a suspected dx can be primary if it's being worked up; however, the MDS coordinator disagrees and feels the encephalopathy should be primary. I'm hesitant to do so because of all the documentation that makes it sound like it is no longer present. I have requested that if the medical team feels the encephalopathy is a more appropriate primary, then a clear concise note needs to be added to the chart documenting the encephalopathy as current and being treated. (MDS coordinator feels there's enough documentation supporting it, however). To date, a note has not been added.

I just want to be sure that I am on the right track with this, and not overlooking something (or causing a headache unnecessarily).

Any input and advice is immensely appreciated. Please let me know if additional information may be needed.

Thank you,
Jessica

 

[sls314]

What was the reason that the SNF stay was approved? Do you have that information?

 

[jtrong]

What was the reason that the SNF stay was approved? Do you have that information?

I actually was not provided that information. I do know that her payor was MCA Replacement Levels- United Healthcare. I just looked at her records and it looks like the physician at the home put "paroxysmal a-fib" on the Part A certification.

Just of note, I'm still fairly new to this position and am still learning the ins and outs of everything. I appreciate the help!

 

[aackary]

Hi Jessica! I realize your post above is almost 2 years old now, but I am wondering if you are still coding for a SNF? I just started at one in October of this year and am really struggling for information. This is my first job in a medical facility. I have gathered that the coding function here it is very different than say in a hospital or pro-fee type position. There is no CPT or HCPCS coding. I have no one here who knows anything about typical coding, only an MDS coordinator who has been doing all of the Admission Diagnosis coding herself according to MDS requirements. They hired me as the Medical Records Coordinator with a little coding on the side I guess. I thought it was a regular full time coding position based on the job description. I didn't know how different it would be, and I guess the interviewers didn't know enough about coding to articulate that to me in the interview. I'm finding that MDS coding can significantly conflict with regular CMS coding guidelines...? I've read that MDS coding follows something called RAI guidelines, which are generally more "stringent" (not sure how-so) than our regular coding guidelines. Basically I need someone that can explain to me what my part is in this unique coding process. It's evidently a very small part, which is not what I was seeking. It's all Diagnosis coding, on Admission to the SNF, then the codes for each patient have to manually be pulled over each month in EPIC throughout the patient's stay, which can be long term or short term. The MDS person maintains a Nursing license for her job, and periodically updates the patient's codes according to their condition. But she is looking for the "highest paying codes" (her words) to enter for the Primary Diagnosis. Payment to the SNF is based on the PDPM (Patient Driven Payment Model), so it's not like billing for individual services or stays. I think it's a per diem type reimbursement based on the previous year's total average intake and case mix...? So I get why there is no procedure coding. But I don't understand how to arrive at the same codes or sequences that she does. I'm completely lost. And no one here seems to be able to explain things to me. I'm AAPC certified. I know how I was trained to code. But now I'm not sure if I just don't know enough about coding for SNFs or if the coding for this facility has been done completely wrong for some time now, and because no one else knows regular coding they think I'm crazy for asking questions. Can you offer any guidance? Like what is the proper way to code a new Resident? They had to have been in a hospital for at least 3 days to be admitted here, so there is a Discharge Summary and other Notes and Op Reports, etc to review to pick an Admission code and a primary Dx code, but what determines which condition is Primary? Apparently it's not what I thought. Is it ok for MDS to just pick the highest paying code as primary? That feels wrong. But maybe I'm way off base?

 

[TThivierge]

Hello Jessica and AAcary
Here are some issue to be aware of SNF .The patients must have assessment done. The RAF Resident Assessment Form done so many days..8, 14, 60 and 90 days by provider to ensure getting right treatment for chronic issues or special needs. Initial nursing home CPT 9904-99306 and must be at least 25 minutes long with list of chronic conditions and risk complications. Subsequent ongoing treatment at SNF use CPT 99307- 99316 at least 10 minutes documented & treated SNF discharges from CPT 99315- 99316. Does your facility physicians or providers do Advance Care (death planning noted in med record)see CPT 99497 -99498 for at least 30 minutes and discussion noted in med record for the data billed. Transitional Care if pt coming from a inpatient hospital can be done too ..2 days after release from inpt. status. See CPT codes 99495 -99498. Ensure document inpt hospital name and dates when released the notation on medical issues.
Chronic conditions the top 8 should be documented if patient suffers with it, combination diseases, and forever disease. Plus if missing organs, device implanted in, or transplants document this too with certain medication and if current or past smoker. Some dx codes risk adjust and some do not.
Use admit forms on why is patient seeking SNF care...car accident , COPD, acute heart condition, dementia, paralyzed, stroke?
I hope this data helps you
Lady T