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July 26, 2017

ICD-9 to ICD-10 Conversion and PASRR

Since the ICD-10-CM coding went into effect on October 1, 2015, some State PASRR programs have reported an increase in PASRR volume, particularly in referrals for Level II Resident Reviews. The increase is largely attributed to the computer algorithm that converted ICD-9 codes to ICD-10 codes. NF residents coded under ICD-9 as having a minor depression - i.e. not a depression severe enough to meet PASRR’s definition of “severe mental illness” (SMI) - were, when the system converted to the ICD-10 system, being coded as having a major depression (specifically many residents received a coding of F32.9 ”major depression – unspecified”).

When it was first written, PASRR required that all NF residents with SMI receive an annual Resident Review. In 1997, the requirement was amended to indicate that a Resident Review should be performed for residents experiencing a “significant change in mental or physical status.” Ordinarily a coding change indicating a progression from minor to major depression would constitute such a “significant change” obligating the NF to refer the resident to the SMHA, which in turn would determine if a Level II evaluation was necessary. However, since the conversion to ICD-10 coding, State SMHAs have reported a higher-than-average volume of referrals for residents who have not actually experienced a material change in mental status – they had simply been re-coded by the computer system as having F32.9 major depression.

The transition to the ICD-10 coding system clearly had an unintended consequence on State PASRR programs. However, CMS has confirmed that it cannot instruct States to exempt from the Resident Review process residents recently identified as having F32.9 major depression, or receiving other new codes as a result of the conversion to ICD-10 with the possible exception described below. While some residents may be incorrectly identified as having a change in mental status, or even misidentified as having a major depression, other residents may truly be experiencing a change in mental status that warrants a full Level II evaluation. These determination must still be made on a case-by-case basis.

ICD-10 codes should accurately reflect the resident’s physical and mental health, and should not be altered out of concern of triggering PASRR. A diagnosis, or a history of diagnosis, of a mental disorder (including major depression) may not be enough to trigger PASRR if that mental disorder does not meet the timeframe or severity described in 42 CFR 483.102(b). SMHAs are not required to recommend a full Level II evaluation if they are able to determine, using appropriate clinical judgment, that the resident’s apparent change in mental status is the result of a coding change or error.

States are encouraged to support their PASRR Programs to the best of their ability during the temporary increase in PASRR referrals. Because the transition from ICD-9 to ICD-10 coding was a one-time transition, the number of residents being flagged as needing a Resident Review determination due to coding error should diminish once they have been referred. PASRR programs with access to MDS data may wish to compare “before” and “after” lists of residents to identify those whose change corresponds with the same date as the switch to ICD-10. Such likely “false positives” without anything else to suggest an actual status change, do not require a Resident Review.

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