What’s in a primary diagnosis?

Have you ever walked out of a restaurant after a filling meal with an empty feeling in your stomach? I have. It is the feeling one gets after eating sushi without wasabi, Korean food without kimchi, and Thai curry without hot chilis. While food serves to nourish our bodies, the salt and spice make eating it desirable. Without the flavor and taste we crave food is nothing more than bland sustenance. Under PDPM, the primary diagnosis captured on the Initial MDS Assessment drives the flavor of the stay, especially the amount CMS pays at checkout. And, you guessed it, there is no gratuity included!

Why is the primary diagnosis so important? It is common knowledge that the Initial MDS Assessment is meant to capture the residents’ characteristics upon admission to a SNF for Medicare A stays, and this in turn drives reimbursement for services provided during the entire stay, unless an IPA is performed. The primary diagnosis maps the residents’ clinical category to one of 13 predefined categories, and therefore identifies the base rate for reimbursement for the care episode. Errors in categorization could mean a variance in rates by $100 a day or more!

The ‘why’

What is the primary diagnosis? The simple answer: it is the reason for the skilled nursing stay. It is not “how” residents got there, but “why.” Therefore, in a vast majority of cases, hospital diagnoses perhaps are not the best answers. Hospitals tend to treat acute conditions and generally, by the time residents come to SNFs, the acuity would have worn off. If the acute condition persists and is the driver of much of the care and services a resident requires in SNF, such as an aspiration pneumonia ­still being treated with intravenous antibiotics, respiratory therapy, oxygen, nebulizers, and speech therapy for associated dysphagia, perhaps that is a good primary diagnosis. However, if the resident is doing better on oral antibiotics and has Parkinson’s disease or a previous stroke that is the underlying problem that requires much of the care and rehabilitation, then that should be the primary diagnosis.

A timely and thorough clinical assessment of every new admission is therefore crucial to establishing the primary diagnosis. It is tempting to look at the myriad ICD 10 codes that accompany a resident from the hospital and pick one that looks complicated, usually involving a vital organ system, such as heart failure or lung disease. Unless the care being provided revolves around these diagnoses, the resident will be mapped to a medical management category, which carries one of the lower reimbursement rates. Such mistakes are easily avoided if the ‘why’ question is consistently entertained.