On-Demand Webinar: Declutter Your Coding - Spring Cleaning Tips for ICD-10-CM Success in LTC-Recording: Declutter Your Coding - Spring Cleaning Tips for ICD-10-CM Success in LTC

Video Transcription

Video Summary

The presentation focused on improving ICD-10-CM coding accuracy in long-term care, with an emphasis on compliance, reimbursement, and quality reporting. It explained that coding is often handled by nurse assessment coordinators in SNFs and should be supported by the interdisciplinary team, but ultimately owned by a designated facility coder who reviews provider documentation, queries clinicians when needed, and assigns codes using official ICD-10 guidelines.<br /><br />Key topics included the importance of distinguishing active, resolved, historical, acute, chronic, and acute-on-chronic conditions; understanding etiology vs. manifestation coding; and using the highest level of specificity supported by the medical record. The speaker warned against overreliance on EHR auto-population, default codes, or unspecified codes when more detail is available. Unspecified codes are appropriate when documentation lacks detail, but not when the record supports a more specific diagnosis.<br /><br />The session also reviewed how diagnosis coding affects PDPM, Section I of the MDS, and quality measures. Examples were given around schizophrenia, CKD, CVA sequelae, and dementia coding. The speaker stressed that diagnoses must be supported by physician documentation, and that resolving or deleting diagnoses requires proper documentation or orders, not just staff judgment.<br /><br />Finally, the speaker reviewed April ICD-10 updates, noting no new codes but several instructional note changes, and reminded attendees to use the 2026 ICD-10-CM manual along with the April addendum. The overall message: accurate documentation, regular review, and timely provider queries are essential for clean coding and better outcomes.

Keywords

ICD-10-CM coding

long-term care

SNF documentation

compliance

reimbursement

quality reporting

PDPM

MDS Section I

provider queries

diagnosis specificity