Top 50 skilled nursing facilities diagnoses

Skilled nursing facilities (SNFs) play an increasingly important role in the healthcare continuum, particularly as the elderly patient population continues to grow. Definitive Healthcare tracks data on more than 20,000 skilled nursing facilities.

As SNFs frequently provide care to elderly patients and Medicare beneficiaries, we examined the most common diagnoses by both Medicare and commercial claims data.

50 most common ICD-10 codes for skilled nursing facilities by total Medicare payments

Rank	ICD-10 Code	ICD-10 Description	# of Claims	Avg Pmt/Claim	Total Pmts	Total Charges
	U071	COVID-19	241,611	$6,375	$1,540,286,133	$2,298,773,633
	N390	Urinary tract infection, site not specified	85,913	$6,778	$582,302,864	$871,886,834
	G9341	Metabolic encephalopathy	75,214	$7,552	$568,026,112	$790,136,975
	A419	Sepsis, unspecified organism	50,596	$7,585	$383,779,493	$531,386,915
	Z4789	Encounter for other orthopedic aftercare	49,300	$7,652	$377,240,679	$554,723,478
	Z471	Aftercare following joint replacement surgery	49,662	$7,267	$360,878,917	$517,827,144
	J189	Pneumonia, unspecified organism	50,595	$6,903	$349,260,803	$517,012,315
	I639	Cerebral infarction, unspecified	44,563	$7,459	$332,377,271	$512,084,652
	G9340	Encephalopathy, unspecified	42,662	$7,445	$317,615,897	$445,014,236
	J9601	Acute respiratory failure with hypoxia	39,968	$7,305	$291,970,308	$418,720,777
	G20	Parkinson's disease	43,191	$6,730	$290,690,830	$489,029,450
	J449	Chronic obstructive pulmonary disease, unspecified	42,888	$6,025	$258,399,026	$449,367,059
	Z4781	Encounter for orthopedic aftercare following surgical amputation	22,627	$8,190	$185,316,459	$265,533,164
	I69354	Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side	23,426	$7,712	$180,660,441	$295,400,162
	S72002D	Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing	22,059	$7,942	$175,197,163	$255,819,791
	Z48815	Encounter for surgical aftercare following surgery on the digestive system	23,587	$7,346	$173,277,247	$250,877,209
	S72001D	Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing	21,799	$7,933	$172,936,705	$255,772,501
	J441	Chronic obstructive pulmonary disease with (acute) exacerbation	24,343	$6,918	$168,407,593	$254,320,166
	I69351	Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side	21,185	$7,786	$164,945,721	$264,272,492
	N179	Acute kidney failure, unspecified	25,344	$6,376	$161,598,341	$253,382,262
	S72142D	Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing	20,382	$7,877	$160,543,373	$244,827,744
	R531	Weakness	8,227	$18,761	$154,350,730	$223,437,144
	S72141D	Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing	18,628	$7,985	$148,753,547	$226,691,032
	I509	Heart failure, unspecified	24,426	$6,038	$147,493,328	$245,830,476
	M6259	Muscle wasting and atrophy, not elsewhere classified, multiple sites	16,181	$7,906	$127,921,849	$159,782,153
	R278	Other lack of coordination	15,812	$8,047	$127,246,582	$162,113,036
	F0390	Unspecified dementia without behavioral disturbance	33,045	$3,753	$124,021,202	$360,999,291
	I4891	Unspecified atrial fibrillation	20,957	$5,833	$122,240,193	$210,274,145
	J9621	Acute and chronic respiratory failure with hypoxia	15,407	$7,491	$115,407,256	$173,542,517
	M6282	Rhabdomyolysis	14,534	$7,754	$112,697,000	$160,661,412
	Z48812	Encounter for surgical aftercare following surgery on the circulatory system	15,796	$7,088	$111,969,042	$163,079,236
	L03115	Cellulitis of right lower limb	14,218	$7,718	$109,734,556	$157,913,350
	I5033	Acute on chronic diastolic (congestive) heart failure	17,526	$6,129	$107,413,791	$173,477,619
	L03116	Cellulitis of left lower limb	13,894	$7,640	$106,149,347	$155,605,109
	N186	End stage renal disease	16,662	$6,153	$102,527,928	$164,095,342
	I214	Non-ST elevation (NSTEMI) myocardial infarction	15,369	$6,321	$97,154,052	$150,516,260
	R5381	Other malaise	4,367	$20,602	$89,969,884	$118,573,769
	M545	Low back pain	12,077	$7,417	$89,572,928	$129,573,196
	R55	Syncope and collapse	13,470	$6,359	$85,660,463	$134,526,050
	E119	Type 2 diabetes mellitus without complications	14,739	$5,628	$82,954,238	$159,150,115
	F0391	Unspecified dementia with behavioral disturbance	20,365	$4,032	$82,113,899	$211,405,105
	J690	Pneumonitis due to inhalation of food and vomit	11,301	$7,190	$81,254,883	$119,225,255
	I6930	Unspecified sequelae of cerebral infarction	9,728	$7,621	$74,141,172	$112,838,909
	G92	Toxic encephalopathy	9,270	$7,931	$73,522,930	$97,712,673
	G35	Multiple sclerosis	11,197	$6,471	$72,453,682	$129,976,565
	D649	Anemia, unspecified	11,352	$6,125	$69,527,947	$114,056,895
	I2510	Atherosclerotic heart disease of native coronary artery without angina pectoris	12,368	$5,450	$67,409,857	$128,304,341
	S7291XD	Unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing	8,356	$7,970	$66,594,424	$97,214,942
	I5023	Acute on chronic systolic (congestive) heart failure	10,268	$6,232	$63,985,434	$99,479,159
	M869	Osteomyelitis, unspecified	6,450	$9,805	$63,240,985	$79,802,660

Fig 1. – Data from the Definitive Healthcare LongTermCareView product. Data is for 2021 YTD through September. Annual Medicare data is from the Centers for Medicare and Medicaid (CMS) Medicare Standard Analytical Files (SAF). Complete calendar year data is projected be released each fall. which has an approximate 93% claims maturity for each quarter. Quarterly claims data is released by CMS approximately five to six months after the end of each quarter. New claims data is expected to be incorporated into the Definitive Healthcare database within 4-5 weeks. Data accessed April 2022.

50 most common ICD-10 codes for skilled nursing facilities by total charges to commercial payors

Rank	ICD-10 Code	ICD-10 Description	# Total Diagnoses	# Principal Diagnoses	Total Charges
	U071	COVID-19	933,467	566,371	$1,852,820,891
	J449	Chronic obstructive pulmonary disease, unspecified	1,359,224	339,287	$1,027,708,704
	F0390	Unspecified dementia without behavioral disturbance	1,169,456	319,759	$1,021,860,249
	I10	Essential (primary) hypertension	4,370,070	677,926	$855,328,570
	G309	Alzheimer's disease, unspecified	402,948	192,010	$731,302,880
	I639	Cerebral infarction, unspecified	469,517	194,144	$697,838,109
	N390	Urinary tract infection, site not specified	733,524	224,039	$682,595,076
	G20	Parkinson's disease	388,461	170,485	$678,761,583
	G9341	Metabolic encephalopathy	244,925	105,936	$570,345,930
	F0391	Unspecified dementia with behavioral disturbance	441,553	155,846	$540,656,624
	N186	End stage renal disease	289,315	93,244	$512,707,538
	A419	Sepsis, unspecified organism	248,539	100,199	$479,496,173
	E119	Type 2 diabetes mellitus without complications	1,667,225	262,186	$479,182,429
	J9601	Acute respiratory failure with hypoxia	327,620	108,599	$435,203,153
	M6281	Muscle weakness (generalized)	2,846,241	349,956	$412,183,497
	J189	Pneumonia, unspecified organism	355,165	126,122	$389,672,715
	G9340	Encephalopathy, unspecified	208,969	77,016	$379,041,394
	I69354	Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side	191,517	76,029	$375,978,947
	I509	Heart failure, unspecified	666,353	144,268	$373,286,329
	Z4789	Encounter for other orthopedic aftercare	148,312	57,824	$367,511,494
	I69351	Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side	178,982	73,987	$360,506,839
	J9610	Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia	110,244	47,903	$313,390,969
	G301	Alzheimer's disease with late onset	173,413	90,786	$310,096,904
	J441	Chronic obstructive pulmonary disease with (acute) exacerbation	211,548	86,794	$308,928,561
	G35	Multiple sclerosis	137,652	74,757	$306,171,027
	I2510	Atherosclerotic heart disease of native coronary artery without angina pectoris	1,014,621	119,676	$305,596,315
	Z471	Aftercare following joint replacement surgery	78,456	45,969	$293,826,943
	I4891	Unspecified atrial fibrillation	799,124	117,298	$263,050,503
	N179	Acute kidney failure, unspecified	446,807	85,370	$261,478,337
	Z4781	Encounter for orthopedic aftercare following surgical amputation	47,484	30,932	$209,071,055
	F209	Schizophrenia, unspecified	248,337	71,195	$201,713,155
	J9621	Acute and chronic respiratory failure with hypoxia	112,410	46,101	$186,201,024
	G311	Senile degeneration of brain, not elsewhere classified	45,187	33,156	$180,518,247
	J9611	Chronic respiratory failure with hypoxia	148,797	46,673	$167,559,193
	R1312	Dysphagia, oropharyngeal phase	761,599	52,046	$164,801,849
	S72002D	Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing	51,178	31,261	$164,270,446
	S72001D	Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing	52,145	31,475	$161,896,099
	Z48815	Encounter for surgical aftercare following surgery on the digestive system	45,948	23,035	$157,798,509
	D649	Anemia, unspecified	1,001,722	102,388	$153,312,362
	S72142D	Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing	36,987	24,558	$152,961,596
	Z430	Encounter for attention to tracheostomy	45,505	3,983	$148,518,504
	I6930	Unspecified sequelae of cerebral infarction	85,807	30,943	$148,296,893
	I5033	Acute on chronic diastolic (congestive) heart failure	102,567	37,275	$141,529,331
	F259	Schizoaffective disorder, unspecified	131,675	38,342	$139,371,731
	R55	Syncope and collapse	138,025	39,959	$138,597,417
	S72141D	Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing	33,298	22,268	$135,077,088
	M6259	Muscle wasting and atrophy, not elsewhere classified, multiple sites	206,941	34,145	$133,261,190
	G809	Cerebral palsy, unspecified	60,466	32,009	$132,333,857
	I5032	Chronic diastolic (congestive) heart failure	255,902	48,210	$132,026,393
	I739	Peripheral vascular disease, unspecified	545.275	75,756	$131,153,761

Fig 2. – Data is from the Definitive Healthcare ClaimsMx product for the calendar year 2021. Claims data is sourced from multiple medical claims clearinghouses in the United States and is updated monthly. Data is accurate as of April 2022.

What are the most common skilled nursing facility diagnoses?

Unsurprisingly, COVID-19 tops the list as the most common diagnosis at SNFs both by Medicare and commercial claims data. Long-term care facilities like SNFs were hit particularly hard at the start of the pandemic. As the patient population tends to be elderly, most patients fall into the high-risk category for COVID-19.

Urinary tract infections (UTIs) take second place when looking at Medicare payments and make the top ten by commercial insurance charges. For years, UTIs have been one of the most common long-term care facility infections. If left untreated, UTIs can lead to sepsis, a life threatening condition. Sepsis comes in fourth on the top diagnosis by Medicare payments and the top 15 by commercial claims.

Other common diagnoses at SNFs include respiratory illnesses such as pneumonia and COPD, neurological disorders such as encephalopathy and dementia, and orthopedic conditions.

What is a skilled nursing facility (SNF)?

A skilled nursing facility is an inpatient facility types that provides short- or long-term rehabilitation services. These facilities provide 24-hour licensed medical support to patients requiring transitional care following a qualifying hospital stay for illness, injury or surgery.

The facilities primarily serve elderly patients and the majority of SNFs are Medicare-certified. Medicare beneficiaries are covered for up to 100 days in a SNF and face out-of-pocket costs for each additional day they spend in SNF care.

What qualifies a patient for skilled nursing care?

Patients who require skilled rehabilitative therapy or skilled nursing care typically qualify for a set number of days of skilled nursing care.

Under Medicare, beneficiaries are covered for SNF care if:

They have Medicare Part A and have days left in their benefit period available for use.
They were formally admitted to inpatient care at a hospital for three consecutive days.
They entered a Medicare-certified SNF within 30 days of leaving the hospital and receiving care for the same condition they were treated for during their hospital stay.
Their doctor has decided they required daily skilled care that needs to be received from, or under the supervision of skilled nursing or therapy staff.

Patients who required skill nursing care can typically receive the following services at SNF facilities:

Medication management
Assistance with daily living activities
Meal preparation and dietary counseling
Wound care
Physical, occupational, and/or speech therapy
Cardiac rehabilitation
Post-stroke rehabilitation

What is the difference between a skilled nursing facility, assisted living and a nursing home?

The biggest difference between skilled nursing facilities and assisted living facilities is that SNFs provide medical care while assisted living facilities provide more personal care in a home-like, social setting. Residents in an assisted living facility may only need moderate amounts of clinical care whereas those in skilled nursing require 24/7 care or rehabilitation services.

The biggest difference between a skilled nursing facility and a nursing home is that a nursing home tends to be more of a permanent residence for people who need long-term 24/7 care. SNFs are temporary residences for patients undergoing necessary rehabilitation or skilled nursing care, typically after a hospital stay, with a limited timeframe for care.

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