Top Skilled Nursing Facility Diagnoses

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).

Top 50 Skilled Nursing Facilities Diagnoses

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Top 50 Skilled Nursing Facility Diagnoses by Total Payments

Top 50 Skilled Nursing Facilities Diagnoses

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Top 50 Skilled Nursing Facility Diagnoses by Total Payments