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The growing population of elderly and their higher share of overall health spending have made skilled nursing care an increasingly important part of the healthcare continuum. Taking control of post-acute care can lower episodic costs and reduce the likelihood of avoidable conditions. In order to improve care, it’s necessary to understand the patient volumes and conditions that SNFs manage each day. The following list identifies the top 20 ICD-10 diagnoses by total payments.

Unlike in acute care settings, diagnosis coding in SNFs often reflects the cause of admission to the referring hospital, rather than to the nursing facility itself. As a result, the most common and highest reimbursed ICD-10 code at SNFs is Z5189 – encounter for other specified aftercare. This code, along with others in the Z range listed in the top 50, describes patients admitted to an SNF to receive follow-up care for an existing condition diagnosed and treated in a less-intensive environment, to manage post-hospital discharge ailments, or to prevent immediate recurrence. Most of the rest of the diagnoses are for conditions commonly associated with the elderly, such as pneumonia, heart failure, hip fracture, and mobility problems.

The code with the highest average payments per claim is S72142D – Displaced fracture of left femur, subsequent encounter. Hip dislocations and other major joint injuries typically involve a longer healing time and length of stay, contributing to the higher post-acute care spending and increased follow-up visits. The same is true for many of the other high-cost codes on the list, such as cerebral artery occlusion with cerebral infarction (stroke), neck or femur fracture, and care involving physical therapy (such as breathing exercises or training to regain mobility).

Top 50 Skilled Nursing Facility Diagnoses by Total Payments

  ICD-10 Code Description Number of Claims Average Payment Per Claim Total Payments

1.

Z5189

Encounter for other specified aftercare

222,500

$6,042

$1,344,452,674

2.

M6281

Muscle weakness (generalized)

171,034

$5,589

$955,931,771

3.

J189

Pneumonia, unspecified

153,005

$5,579

$853,672,694

4.

N390

Urinary tract infection, site not specified

148,513

$5,688

$844,775,115

5.

Z471

Aftercare following joint replacement

112,734

$5,955

$671,358,832

6.

I509

Heart failure, unspecified

95,559

$4,759

$454,774,738

7.

I10

Essential (primary) hypertension

83,903

$4,853

$407,219,905

8.

A419

Sepsis, unspecified organism

69,745

$5,727

$399,433,328

9.

R531

Weakness

60,218

$6,514

$392,276,241

10.

I639

Cerebral infarction, unspecified

58,327

$6,606

$385,289,346

11.

Z4789

Encounter for other orthopedic aftercare

57,416

$6,681

$383,620,763

12.

J449

Chronic obstructive pulmonary disease, unspecified

82,459

$4,484

$369,755,738

13.

J441

Chronic obstructive pulmonary disease with (acute) exacerbation

65,257

$5,407

$352,848,001

14.

R4182

Altered mental status, unspecified

50,331

$5,468

$275,202,368

15.

I4891

Unspecified atrial fibrillation

47,979

$4,911

$235,643,299

16.

S72001D

Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing

32,819

$6,959

$228,395,387

17.

R262

Difficulty in walking

38,503

$5,855

$225,439,963

18.

S72002D

Fracture of unspecified part of left femur, subsequent encounter for closed

fracture with routine healing

32,087

$7,004

$224,742,452

19.

N179

Acute kidney failure, unspecified

39,654

$5,555

$220,268,726

20.

R55

Syncope and collapse

36,153

$5,943

$214,870,469

21.

K922

Gastrointestinal hemorrhage, unspecified

40,595

$5,202

$211,184,852

22.

N186

End stage renal disease

37,705

$4,803

$181,082,805

23.

Z9181

History of falling

29,321

$6,025

$176,649,039

24.

Z4889

Encounter for other specified surgical aftercare

27,886

$6,183

$172,422,219

25.

G20

Parkinson's disease

37,883

$4,504

$170,638,564

26.

L03115

Cellulitis of right lower limb

25,300

$6,145

$155,480,706

27.

F0390

Unspecified dementia without

behavioral disturbance

62,973

$2,422

$152,489,145

28.

S72142D

Displaced intertrochanteric fracture of left femur, subsequent encounter

20,541

$7,348

$150,926,142

29.

I214

Non-ST elevation myocardial infarction

26,844

$5,539

$148,690,147

30.

L03116

Cellulitis of left lower limb

22,838

$6,315

$144,231,653

31.

R5381

Other malaise

23,712

$6,050

$143,463,671

32.

Z48812

Encounter for surgical aftercare after circulatory surgery

24,659

$5,815

$143,400,690

33.

J690

Pneumonitis due to inhalation of food and vomit

25,102

$5,712

$143,383,888

34.

Z48815

Encounter for surgical aftercare after digestive surgery

24,603

$5,772

$142,009,088

35.

G9340

Encephalopathy, unspecified

25,585

$5,526

$141,375,482

36.

S72141D

Displaced intertrochanteric fracture of right femur, subsequent encounter

19,585

$7,161

$140,238,473

37.

I2510

Atherosclerotic heart disease of native coronary artery without angina pectoris

29,353

$4,730

$138,828,968

38.

A047

Enterocolitis due to Clostridium difficile

22,946

$5,941

$136,329,620

39.

J9601

Acute respiratory failure with hypoxia

22,379

$5,689

$127,305,426

40.

R296

Repeated falls

20,844

$5,838

$121,688,435

41.

J9600

Acute respiratory failure, unspecified

18,556

$6,222

$115,460,681

42.

G9341

Metabolic encephalopathy

19,755

$5,597

$110,565,685

43.

E119

Type 2 diabetes mellitus w/o comp.

31,280

$3,483

$108,955,534

44.

I5033

Congestive heart failure

18,893

$5,328

$100,652,532

45.

I69354

Hemiplegia and hemiparesis following cerebral infarction, left side

15,368

$6,447

$99,078,638

46.

I69351

Hemiplegia and hemiparesis following cerebral infarction, right side

14,702

$6,524

$95,912,255

47.

G309

Alzheimer's disease, unspecified

45,285

$2,103

$95,245,081

48.

R627

Adult failure to thrive

17,333

$5,467

$94,761,015

49.

D649

Anemia, unspecified

17,446

$5,152

$89,878,306

50.

G459

Transient cerebral ischemic attack,

unspecified

15,500

$5,536

$85,801,568

Fig 1. Data from Definitive Healthcare based on Medicare Data from 2016 Medicare SAF (1/1/2016 - 12/31/2016). Calendar Year 2017 data is projected to be released in fall 2018 by the Centers for Medicare and Medicaid Services (CMS).