MDS item I0020B, the primary diagnosis is Z47.1 - Aftercare following joint replacement surgery and MDS item J2310: Hip replacement, partial or total, should be checked. Here are examples of the difference:Įxample 1 :A patient with severe degenerative osteoarthritis of the right hip, underwent right hip arthroplasty.
For aftercare of a traumatic fracture, assign the acute fracture code with the appropriate 7th character. When is it appropriate to use the aftercare ICD-10 Z codes as the primary medical diagnosis in MDS item I0020B?Īccording to the CMS ICD-10-CM Official Guidelines for Coding and Reporting for Fiscal Year 2021, the aftercare Z codes should not be used for aftercare of traumatic fractures. Let us discuss the coding for major joint replacement conditions. It is important to communicate with the provider to ensure that necessary information is documented in the medical record within the assessment look-back period to identify the appropriate diagnosis codes. Records include the history and physical, recent hospital discharge summary, signed physician’s orders, provider consults, progress notes, and pertinent diagnostic reports. Understanding the International Classification of Diseases (ICD)-10 coding guidelines is one step figuring out the Centers for Medicare and Medicaid Services (CMS) PDPM ICD-10-CM Mappings Fiscal Year 2021 is another key element for the reimbursement calculation.Īssigning ICD-10 codes must be at the highest degree of specificity based on the provider-documented medical records.
Under the Payment-Driven Payment Model (PDPM), the selection of the primary medical diagnosis recorded in the Minimum Data Set (MDS) item I0020B plays a factor in the Medicare Prospective Payment System (PPS) methodology.
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