Top ICD-10 Codes Every Skilled Nursing Facility Should Know for Accurate Billing

Did you know that Skilled Nursing Facilities (SNFs) care for over a million Medicare-covered stays every year?

With such a high volume of patients, even a minor coding error can result in thousands of dollars in lost revenue due to denied claims.

But what are the most common codes that SNFs need to get right? How can facilities ensure that pneumonia, sepsis, or fractures are documented accurately? When should Z-codes or encounter characters be applied?

These questions matter as accurate ICD-10 coding reflects the complexity of patient care and supports compliance with payer requirements. In this blog, we will explore the top ICD-10 codes every SNF should know for accurate billing.

1. Common Diagnoses Codes

There are certain medical conditions that frequently result in hospitalization and subsequent admission to an SNF for post-acute care. As a result, understanding the correct ICD-10 codes for these conditions ensures accurate billing and reflects the complexity of patient care.

1.1 Pneumonia (J18.9)

The ICD-10 code J18.9 is used when the specific causative organism is unknown. But if the exact organism is identified, a more specific code should be applied to improve documentation accuracy and support reimbursement.

1.2 Urinary Tract Infection (N39.0)

UTIs are very common in SNF patients, especially among the elderly. The code N39.0 is used to denote an unspecified urinary tract infection. Proper coding ensures that these infections are recognized as a key part of the resident’s medical needs.

1.3 Sepsis (A41.9)

A severe and potentially life-threatening infection, Sepsis is coded as A41.9 when the causative organism is unspecified. Accurate coding of sepsis is vital as it reflects the severity of the condition and can impact reimbursement levels.

1.4 Chronic Obstructive Pulmonary Disease (COPD) (J44.9)

COPD is commonly seen in SNF residents particularly those with long-term respiratory issues. Code J44.9 represents unspecified COPD whereas J44.1 is used for acute exacerbations. Using the correct code helps capture the patient's clinical complexity.

1.5 Metabolic Encephalopathy (G93.41)

Metabolic encephalopathy occurs when metabolic imbalances affect brain function. This condition is often a reason for SNF admission and the code G93.41 accurately represents the diagnosis, supporting appropriate care planning.

1.6 Heart Failure (I50.9)

The ICD-10 code I50.9 is used for unspecified heart failure. However, more specific codes, such as I50.23 for acute-on-chronic systolic heart failure, should be used whenever detailed information is available.

1.7 Acute and Chronic Respiratory Failure (J96.21)

Patients requiring respiratory support often experience acute or chronic respiratory failure. J96.21 is used for accurate documentation to ensure that the severity of the patient’s respiratory condition is clearly recorded.

1.8 End-stage Renal Disease (N18.6)

End-stage renal disease requires specialized care and frequent monitoring. Code N18.6 is used to document this advanced stage of kidney disease which often influences treatment plans and reimbursement.

1.9 Alzheimer’s Disease (G30.9)

Alzheimer’s disease is a common form of dementia in SNF residents. G30.9 represents an unspecified diagnosis of Alzheimer’s, but facilities should use more specific sub-codes when the disease stage is known.

2. Aftercare Codes (Z-codes)

Aftercare codes or Z-codes are essential for documenting services related to post-surgical recovery and follow-up care. They provide context for ongoing treatment and help justify medical necessity for billing purposes.

2.1 Aftercare Following Joint Replacement Surgery (Z47.1)

Patients recovering from hip, knee or other joint replacement surgeries require rehabilitative care. Z47.1 captures this aftercare to ensure that claims reflect the post-operative services provided in the SNF.

2.2 Encounter for Other Orthopedic Aftercare (Z47.89)

Z47.89 is used for general orthopedic follow-up care when more specific details are unavailable. Facilities should always select a more precise code if the type of orthopedic service is documented.

2.3 Encounter for Surgical Aftercare Following Surgery on Skin and Subcutaneous Tissue (Z48.817)

This code applies to patients needing wound management and monitoring after skin or subcutaneous tissue surgery. Proper documentation supports billing for services such as dressing changes or suture care.

2.4 Encounter for Attention to Dressings, Sutures, and Drains (Z48.0)

Z48.0 includes codes for changing both surgical (Z48.01) and non-surgical (Z48.00) dressings. Accurate coding ensures that these routine but necessary interventions are recognized and reimbursed.

3. Wound Care Codes

Accurate documentation for wound care is crucial in SNFs as it directly impacts reimbursement and patient care planning.

3.1 Pressure Ulcers (L89.-)

Pressure ulcers are coded according to location and stage. For example, a stage 4 sacral pressure ulcer is coded as L89.154. If the stage is not visible, unstageable codes such as L89.620 are used.

3.2 Non-healing Surgical Wounds (T81.31XD)

T81.31XD represents non-healing surgical wounds that require interventions, such as debridement. The seventh character indicates the type of encounter, such as initial, subsequent, or sequela.

3.3 Non-pressure Chronic Ulcers (L97.-)

These codes are used for chronic ulcers not caused by pressure including diabetic or venous ulcers. In fact, selecting the correct code ensures precise documentation for treatment and reimbursement.

4. Fall-related Codes

Falls are common among SNF residents and require specific ICD-10 coding to accurately document the incident and related injuries.

4.1 Repeated Falls (R29.6)

R29.6 is used when a patient has a history of multiple falls and the cause is under investigation. It helps capture the patient’s vulnerability and informs preventive care strategies.

4.2 History of Falling (Z91.81)

Z91.81 is a secondary code indicating a patient’s risk of future falls based on previous incidents. This code supports medical necessity for preventive interventions.

4.3 External Cause Codes (W00-W19)

External cause codes provide details on how a fall occurred. For instance, W01 represents a fall on the same level due to slipping or tripping. These codes complement injury codes for accurate claim submission.

4.4 Fractures (S72.- for Femur Fractures)

Falls often result in fractures and S72.- codes specify femur fractures, with additional characters indicating laterality and type of encounter, such as subsequent encounters for routine healing (e.g., S72.002D).

Best Practices for SNF Billing

It is essential to provide specific documentation. For instance, codes like J18.9 for pneumonia should only be used when the exact organism causing the pneumonia is unknown. Whenever possible, facilities should select a more detailed code based on the physician's documentation to accurately reflect the patient's condition.

Further, SNFs should sequence codes correctly according to ICD-10 guidelines. For example, when a patient is admitted after a hip fracture, the fracture (S72.-) should be listed as the primary diagnosis, followed by the aftercare code (Z47.89). This proper sequencing ensures that claims clearly reflect both the patient's condition and the services provided to them.

Additionally, Z-codes should be used appropriately. Although codes like Z91.81 (History of falling) cannot typically serve as the primary diagnosis, they are valuable for providing a complete clinical picture and supporting medical necessity when included as secondary codes.

Moreover, it is essential to apply the correct encounter character for injury codes. Many codes require a seventh character to indicate whether the encounter is initial (A), subsequent (D), or a sequela (S). Using the correct character reduces coding errors and supports accurate billing.

Ultimately, outsourcing SNF billing and coding services to 24/7 Medical Billing Services can be highly effective for facilities seeking to save time and ensure accuracy. Their team of experts ensures that all codes, Z-codes, and encounter characters are applied correctly, which minimizes claim denials and maximizes reimbursement.

FAQs

Q1. Do SNFs need to code for secondary diagnoses?

Secondary codes capture the full complexity of patient care.

Q2. Why are Z-codes sometimes underused in SNFs?

Facilities overlook them, though they support medical necessity.

Q3. What tools can help SNFs with ICD-10 coding?

Electronic health record systems and coding software.

Q4. How often do ICD-10 codes get updated?

ICD-10 codes are updated annually, usually every October.