When I was 11 and 12 years old, my older brother and I spent two summers with my grandparents, who lived on a lake in the Northwoods of Wisconsin. It was spectacular.

They owned 10 acres of undeveloped, untouched woods. We had a grand time exploring, helping my Grandpa George tinker with outdoor stuff, listening to my Grandma Violet play her organ and sing hymns in the afternoons, and watching the Milwaukee Brewers play ball.

We also went boating and fishing in an old StarCraft rowboat, to which Grandpa attached a small motor so we could go faster than the oars would allow. I can feel the lake breeze on my face just thinking about it.

As I reminisce on these experiences, some memories are clearer than others, like the smell of the woodshed, Grandma’s Shy Violet Shoppe with all its hidden treasures, and the sound of the ducks quacking loudly and waddling up to Grandpa, who always had an ample supply of corn to feed them.  

Thinking about these things reminds me of an element of the MDS that, until PDPM came along, was largely overlooked, if not outright ignored. I’m talking about ICD-10 coding. 

In the RUG days, only one ICD-10 CM code “mattered.” You can guess which one. The 128% add-on to the PPS rate made it worth the effort to be sure it was on the bill. That was clear then. PDPM changed the game for SNFs.

Remember this!

The science of ICD-10 coding is specificity. Painting a clear picture of the resident’s health conditions through ICD-10 coding is the goal. Usually not the favorite task of those assigned to take it on in the nursing home, it requires a dedicated approach that results in compliance and accurate care planning, reimbursement and quality measures.

Clarity, however, often takes a back seat to efficiency. Facilities, rather than adopt specific processes and provide the resources necessary to ensure accurate, clear ICD-10 coding occurs, find ways to end around the necessary ICD-10 coding conventions out of necessity. 

I loved those summers on the lake and that small boat. When my grandparents passed, my younger brother, an avid fisherman, got to use it. Recently, after several years of disuse, it has come to me. Just having it transports me back to the Northwoods of Wisconsin and those wonderful summer days.

As I have gotten older, though, and further in time from those experiences, my mind has strayed, and some of those memories have faded. 

Likewise, the further we stray from the resources and processes required for accurate ICD-10 coding, the less representative of a clear, specific, ICD-10-compliant health profile the resident’s diagnosis code set becomes.

ICD-10 resources, resources, resources

Every nursing facility should ensure that those tasked with ICD-10 coding have the necessary resources to code diagnoses accurately. 

This begins with understanding the coding guidance and conventions particular to long-term care. The American Association of Post-Acute Nursing has a fantastic four-part virtual coding class taught by Carol Maher. I highly recommend it to providers looking to up their ICD-10 coding game. The current AAPACN RAC-CT and RAC-CTA curriculum also have ICD-10 modules as part of those certification programs.

Skilled coders must also have up-to-date ICD-10 coding resources. There are multiple examples of these tools available. The more useful ones are color-coded to enhance coding convention compliance. Coding resources are also available at the CMS ICD-10 CM website for free and offer the latest guidance as well. 

Cheat sheets, Google searches, hearsay, opinions and ICD-10 codes listed on an H&P are all inadequate. 

Remember that only physicians or non-physician practitioners (NP, PA, CNS) can diagnose. Others may provide necessary details, like the stage of a pressure ulcer, but facilities need diagnosticians who understand something about ICD-10 and are willing to work with facility staff to provide the necessary specificity in their documentation for coders to do their job.

Absent these resources, facilities will not be able to create resident-specific ICD-10 profiles that are clear, concise, accurate and compliant.  

The boat that I have now inherited from my summer days on the lake is in decent shape, but it needs some love. I have begun the process of restoration.  I can’t wait to get it in the water again. 

It may be worth your time to evaluate where ICD-10 processes and resources in your facility need repair.

ICD-10 details

It’s easy for me to fondly remember Grandma’s gift shop, too. I loved just being there. It was a converted upstairs living room and basement. She had seasonal vacationer patrons who would stop in every summer just to chat and make a few purchases. 

Remembering and applying ICD-10 coding conventions, however, takes discipline. These conventions apply to all coding scenarios. Here are some examples from the official ICD-10 CM coding guidelines.

Level of detail in coding: “Diagnosis codes are to be used and reported at their highest number of characters available and to the highest level of specificity documented in the medical record.”

The Alphabetic Index and Tabular List:  “The ICD-10-CM is divided into the Alphabetic Index, an alphabetical list of terms and their corresponding code, and the Tabular List, a structured list of codes divided into chapters based on body system or condition.” Proper ICD-10 coding requires starting with the alphabetic list and then using the tabular list to apply specific coding guidelines.

Proper use of the 7th character: “Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct.” 

Proper sequencing of etiology and manifestation codes: “Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.”

The list goes on …

The rewards of reminiscing 

My mind is full of those summer memories, including collecting milk bottle caps and trading them at the local dairy for free mint chip ice cream cones, and Grandma and Grandpa’s incorrigible schnauzer, Lady, who was constantly running away to the neighbors’ cottages for forbidden pancakes and bacon. 

As I reminisce, I am rewarded with a smile. 

Considering the importance of ICD-10 CM coding, facilities will do well to structure regular reviews of their ICD-10 coding resources and processes as well. 

The reward: accurate, compliant diagnosis coding and the avoidance of negative residuals like poor medical review outcomes.

With proper maintenance, my “new” boat will gift me with years of memories, new and old. 

Maintaining robust ICD-10 capabilities might just help your facility to stray less and remember more.

Joel VanEaton, BSN, RN, RAC-CT, RAC-CTA, is a master teacher and the executive vice president of PAC Regulatory Affairs and Education at Broad River Rehabilitation. For further inquiries, he may be contacted here.

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.

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