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May 1, 2020

COVID-19 ICD-10 Code U07.1 and SNF PDPM Assessment Diagnosis

We have providers reporting claims processing problems related to the April 1, 2020 effective date of applying the new U07.1-2019-nCoV acute respiratory disease ICD-10 CM code when 5-day assessment window overlaps March into April dates of service.

For example, when the MDS ARD is in April [4/1/20] but the DOS is in March [3/25-3/31]. This is creating a problem given the U07.1 code is valid as primary in the MDS grouper April 1 but not on the UB-04 for DOS prior to April 1.

Specifically, this is creating a primary diagnosis conflict whereby providers cannot match the primary diagnosis on the UB-04 in form locator 67 with the primary reason for skilled care in item I0020B of the MDS. At this point there does not to be clear and consistent guidance from the MACs regarding how to address this.

Based on the following guidance from the CMS PDPM FAQs question 1.8 (below) is to tell providers with a 5-Day PPS MDS with an April 2020 ARD, but a lookback period that extends into March 2020 that, when applicable, they can use the COVID 19 ICD-10 code U07.1 in MDS item I0020B to obtain the appropriate PDPM case-mix classification, but that the claim associated with March DOS must contain a different ICD-10 code that applies to the beneficiary and that was valid in March.

1.8 – is it required that the principal diagnosis on the SNF claim match the primary diagnosis coded in item I0020B? While we expect that these diagnoses should match, there is no claims edit that will enforce such a requirement.

We understand that this is a one-time event that only impacts a relatively small number of admissions related to COVID-19 that spanned the March-April implementation of the new U07.1 diagnosis code. The claim will need to contain a different diagnosis other than U07.1 but the assessment may contain U07.1 code in these instances.

SNF Waiver to Extend the Benefit Period

Due to the COVID-19 pandemic, CMS utilized its authority under section 1812(f) of the Social Security Act to waive certain Medicare requirements under the SNF PPS. Specifically, for patients who have exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without first having to start a new benefit period. This waiver applies only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances.

In cases where a patient qualifies for renewed SNF benefits under this waiver, the following impacts on typical billing and assessment processes would occur:

  1. For patients that have exhausted their 100 day SNF benefit period and have begun, but not yet completed, the process of ending the current benefit period, the patient's renewed benefit period would be treated as a new SNF stay. This means that providers would be required to complete a 5-day assessment and the variable per diem schedule would begin on Day 1.
  2. For patients that exhaust their 100 day SNF benefit period during a SNF stay and continue the SNF stay under renewed SNF benefits, the patient must be discharged from the SNF stay on the day the patient's benefits exhaust. This includes completing a PPS Discharge Assessment. The patient would then be admitted to a new SNF stay beginning on the first day of the renewed benefits. This means that providers would be required to complete a 5-day assessment and the variable per diem schedule would begin on Day 1.

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