CLARIFICATION ON RECENTLY ADDED ICD-10 CODES

Recently, new ICD-10 codes were introduced off-cycle for COVID-19 effective January 1, 2021 and CMS posted updated coding guidance when there was a COVID-related condition. Additionally, CMS updated the PDPM Mappings file to incorporate the newly introduced codes. Some of the new COVID-19 related codes map to RTP and cannot be used as primary reason for SNF stay in item I0020B of the MDS. Several members have raised concerns about coding on a PPS 5-day or IPA assessment if the patient has previously tested positive for COVID and was symptomatic but since then they have tested negative, but needs skilled care due to a COVID-related condition (i.e. pneumonia). AHCA asked CMS to clarify and they provided the below response. AHCA recommends that you forward this information to MDS assessment and billing staff. AHCA has requested that CMS add this clarification to their published COVID-19 guidance which make some time due to clearance processes so we are sharing this information in the meantime.

When we updated the ICD-10 code mappings for the SNF PDPM clinical categories effective 1/1/2021, we added four new codes related to a diagnosis of COVID-19 to the Return to Provider (RTP) category. Specifically, code J1282, Pneumonia due to coronavirus disease 2019 ; code Z1152, Encounter for screening for COVID-19 ; code Z20822, Contact with and (suspected) exposure to COVID-19 ; and code Z8616, Personal history of COVID-19 , were added to the code mappings.

These RTP codes cannot be used as a primary diagnosis code for a Part A SNF patient. However, in some cases, a patient may receive a diagnosis of pneumonia due to COVID-19 (J1282), which becomes the primary reason for their SNF stay, even after the patient subsequently tests negative for COVID-19. In these cases, as long as the patient still has COVID-associated pneumonia, code U07.1 should continue to be assigned, and U07.1 would be sequenced first. Code J1282 cannot be sequenced first.

This is in accordance with the “code first” guidance in the ICD-10-CM Official Guidelines for Coding and Reporting (available online at https://www.cms.gov/files/document/2021-coding-guidelines-updated-12162020.pdf).