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

  1.  

U071

COVID-19

241,611

$6,375

$1,540,286,133

$2,298,773,633

  1.  

N390

Urinary tract infection, site not specified

85,913

$6,778

$582,302,864

$871,886,834

  1.  

G9341

Metabolic encephalopathy

75,214

$7,552

$568,026,112

$790,136,975

  1.  

A419

Sepsis, unspecified organism

50,596

$7,585

$383,779,493

$531,386,915

  1.  

Z4789

Encounter for other orthopedic aftercare

49,300

$7,652

$377,240,679

$554,723,478

  1.  

Z471

Aftercare following joint replacement surgery

49,662

$7,267

$360,878,917

$517,827,144

  1.  

J189

Pneumonia, unspecified organism

50,595

$6,903

$349,260,803

$517,012,315

  1.  

I639

Cerebral infarction, unspecified

44,563

$7,459

$332,377,271

$512,084,652

  1.  

G9340

Encephalopathy, unspecified

42,662

$7,445

$317,615,897

$445,014,236

  1.  

J9601

Acute respiratory failure with hypoxia

39,968

$7,305

$291,970,308

$418,720,777

  1.  

G20

Parkinson's disease

43,191

$6,730

$290,690,830

$489,029,450

  1.  

J449

Chronic obstructive pulmonary disease, unspecified

42,888

$6,025

$258,399,026

$449,367,059

  1.  

Z4781

Encounter for orthopedic aftercare following surgical amputation

22,627

$8,190

$185,316,459

$265,533,164

  1.  

I69354

Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side

23,426

$7,712

$180,660,441

$295,400,162

  1.  

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

  1.  

Z48815

Encounter for surgical aftercare following surgery on the digestive system

23,587

$7,346

$173,277,247

$250,877,209

  1.  

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

  1.  

J441

Chronic obstructive pulmonary disease with (acute) exacerbation

24,343

$6,918

$168,407,593

$254,320,166

  1.  

I69351

Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side

21,185

$7,786

$164,945,721

$264,272,492

  1.  

N179

Acute kidney failure, unspecified

25,344

$6,376

$161,598,341

$253,382,262

  1.  

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

  1.  

R531

Weakness

8,227

$18,761

$154,350,730

$223,437,144

  1.  

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

  1.  

I509

Heart failure, unspecified

24,426

$6,038

$147,493,328

$245,830,476

  1.  

M6259

Muscle wasting and atrophy, not elsewhere classified, multiple sites

16,181

$7,906

$127,921,849

$159,782,153

  1.  

R278

Other lack of coordination

15,812

$8,047

$127,246,582

$162,113,036

  1.  

F0390

Unspecified dementia without behavioral disturbance

33,045

$3,753

$124,021,202

$360,999,291

  1.  

I4891

Unspecified atrial fibrillation

20,957

$5,833

$122,240,193

$210,274,145

  1.  

J9621

Acute and chronic respiratory failure with hypoxia

15,407

$7,491

$115,407,256

$173,542,517

  1.  

M6282

Rhabdomyolysis

14,534

$7,754

$112,697,000

$160,661,412

  1.  

Z48812

Encounter for surgical aftercare following surgery on the circulatory system

15,796

$7,088

$111,969,042

$163,079,236

  1.  

L03115

Cellulitis of right lower limb

14,218

$7,718

$109,734,556

$157,913,350

  1.  

I5033

Acute on chronic diastolic (congestive) heart failure

17,526

$6,129

$107,413,791

$173,477,619

  1.  

L03116

Cellulitis of left lower limb

13,894

$7,640

$106,149,347

$155,605,109

  1.  

N186

End stage renal disease

16,662

$6,153

$102,527,928

$164,095,342

  1.  

I214

Non-ST elevation (NSTEMI) myocardial infarction

15,369

$6,321

$97,154,052

$150,516,260

  1.  

R5381

Other malaise

4,367

$20,602

$89,969,884

$118,573,769

  1.  

M545

Low back pain

12,077

$7,417

$89,572,928

$129,573,196

  1.  

R55

Syncope and collapse

13,470

$6,359

$85,660,463

$134,526,050

  1.  

E119

Type 2 diabetes mellitus without complications

14,739

$5,628

$82,954,238

$159,150,115

  1.  

F0391

Unspecified dementia with behavioral disturbance

20,365

$4,032

$82,113,899

$211,405,105

  1.  

J690

Pneumonitis due to inhalation of food and vomit

11,301

$7,190

$81,254,883

$119,225,255

  1.  

I6930

Unspecified sequelae of cerebral infarction

9,728

$7,621

$74,141,172

$112,838,909

  1.  

G92

Toxic encephalopathy

9,270

$7,931

$73,522,930

$97,712,673

  1.  

G35

Multiple sclerosis

11,197

$6,471

$72,453,682

$129,976,565

  1.  

D649

Anemia, unspecified

11,352

$6,125

$69,527,947

$114,056,895

  1.  

I2510

Atherosclerotic heart disease of native coronary artery without angina pectoris

12,368

$5,450

$67,409,857

$128,304,341

  1.  

S7291XD

Unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing

8,356

$7,970

$66,594,424

$97,214,942

  1.  

I5023

Acute on chronic systolic (congestive) heart failure

10,268

$6,232

$63,985,434

$99,479,159

  1.  

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

  1.  

U071

COVID-19

933,467

566,371

$1,852,820,891

  1.  

J449

Chronic obstructive pulmonary disease, unspecified

1,359,224

339,287

$1,027,708,704

  1.  

F0390

Unspecified dementia without behavioral disturbance

1,169,456

319,759

$1,021,860,249

  1.  

I10

Essential (primary) hypertension

4,370,070

677,926

$855,328,570

  1.  

G309

Alzheimer's disease, unspecified

402,948

192,010

$731,302,880

  1.  

I639

Cerebral infarction, unspecified

469,517

194,144

$697,838,109

  1.  

N390

Urinary tract infection, site not specified

733,524

224,039

$682,595,076

  1.  

G20

Parkinson's disease

388,461

170,485

$678,761,583

  1.  

G9341

Metabolic encephalopathy

244,925

105,936

$570,345,930

  1.  

F0391

Unspecified dementia with behavioral disturbance

441,553

155,846

$540,656,624

  1.  

N186

End stage renal disease

289,315

93,244

$512,707,538

  1.  

A419

Sepsis, unspecified organism

248,539

100,199

$479,496,173

  1.  

E119

Type 2 diabetes mellitus without complications

1,667,225

262,186

$479,182,429

  1.  

J9601

Acute respiratory failure with hypoxia

327,620

108,599

$435,203,153

  1.  

M6281

Muscle weakness (generalized)

2,846,241

349,956

$412,183,497

  1.  

J189

Pneumonia, unspecified organism

355,165

126,122

$389,672,715

  1.  

G9340

Encephalopathy, unspecified

208,969

77,016

$379,041,394

  1.  

I69354

Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side

191,517

76,029

$375,978,947

  1.  

I509

Heart failure, unspecified

666,353

144,268

$373,286,329

  1.  

Z4789

Encounter for other orthopedic aftercare

148,312

57,824

$367,511,494

  1.  

I69351

Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side

178,982

73,987

$360,506,839

  1.  

J9610

Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia

110,244

47,903

$313,390,969

  1.  

G301

Alzheimer's disease with late onset

173,413

90,786

$310,096,904

  1.  

J441

Chronic obstructive pulmonary disease with (acute) exacerbation

211,548

86,794

$308,928,561

  1.  

G35

Multiple sclerosis

137,652

74,757

$306,171,027

  1.  

I2510

Atherosclerotic heart disease of native coronary artery without angina pectoris

1,014,621

119,676

$305,596,315

  1.  

Z471

Aftercare following joint replacement surgery

78,456

45,969

$293,826,943

  1.  

I4891

Unspecified atrial fibrillation

799,124

117,298

$263,050,503

  1.  

N179

Acute kidney failure, unspecified

446,807

85,370

$261,478,337

  1.  

Z4781

Encounter for orthopedic aftercare following surgical amputation

47,484

30,932

$209,071,055

  1.  

F209

Schizophrenia, unspecified

248,337

71,195

$201,713,155

  1.  

J9621

Acute and chronic respiratory failure with hypoxia

112,410

46,101

$186,201,024

  1.  

G311

Senile degeneration of brain, not elsewhere classified

45,187

33,156

$180,518,247

  1.  

J9611

Chronic respiratory failure with hypoxia

148,797

46,673

$167,559,193

  1.  

R1312

Dysphagia, oropharyngeal phase

761,599

52,046

$164,801,849

  1.  

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

  1.  

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

  1.  

Z48815

Encounter for surgical aftercare following surgery on the digestive system

45,948

23,035

$157,798,509

  1.  

D649

Anemia, unspecified

1,001,722

102,388

$153,312,362

  1.  

S72142D

Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing

36,987

24,558

$152,961,596

  1.  

Z430

Encounter for attention to tracheostomy

45,505

3,983

$148,518,504

  1.  

I6930

Unspecified sequelae of cerebral infarction

85,807

30,943

$148,296,893

  1.  

I5033

Acute on chronic diastolic (congestive) heart failure

102,567

37,275

$141,529,331

  1.  

F259

Schizoaffective disorder, unspecified

131,675

38,342

$139,371,731

  1.  

R55

Syncope and collapse

138,025

39,959

$138,597,417

  1.  

S72141D

Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing

33,298

22,268

$135,077,088

  1.  

M6259

Muscle wasting and atrophy, not elsewhere classified, multiple sites

206,941

34,145

$133,261,190

  1.  

G809

Cerebral palsy, unspecified

60,466

32,009

$132,333,857

  1.  

I5032

Chronic diastolic (congestive) heart failure

255,902

48,210

$132,026,393

  1.  

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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