MDS Alert

Question: When should the SNF claim include an ICD-9-CM code for pneumonia for a rehabilitation patient (for example, if he's in a rehab plus extensive services RUG due to IV fluids or an IV antibiotic for pneumonia)?

Answer: The first listed or principal diagnosis on the claim must indicate the reason that the patient requires a skilled level of care. The diagnosis must relate to the reason for the patient's hospitalization, a condition treated during the hospitalization -- or a condition that arose during the SNF stay while the patient was being treated for the hospitalization conditions.

Therefore if the patient is in the X or L categories, pneumonia should be the first listed diagnosis. Next, you could list the treatment diagnosis for rehab, e.g., muscle weakness, gait disturbance, as well as the V codes for the therapy services. The treatment diagnosis is the diagnosis that directly relates to the therapists' plan of treatment. For example, the physician diagnosis would be the pneumonia. The therapist does not treat the pneumonia but, rather, a condition that the pneumonia-related hospitalization has created.

Medicare allows a therapy diagnosis where allowed by state law, or it allows for the POT [plan of treatment] to describe the conditions that the therapist is evaluating or treating. So, if the PT identifies that the patient, for example, has problems with aerobic capacity during activity and difficulty in walking with a description of that difficulty -- all substantiated by tests and measures or functional scales -- the billing and coding department can include those on the bill. And the MDS coordinator can include those conditions on the MDS. By approving the treatment plan, the physician acknowledges those conditions. Or you can obtain a telephone order or clarification to confirm the treatment conditions and frequency of therapy services. As one example, the order might read "PT five times a week for two weeks in order to treat muscle weakness of bilateral lower extremities, decreased aerobic capacity, and difficulty in gait secondary to the pneumonia. OT 3 times a week to instruct in task modification for dressing and toileting due to decreased aerobic capacity and muscle endurance."

Source: Pauline Franko, PT, MCSP, principal of Encompass Consulting & Education LLC in Tamarac, Fla.