Skilled nursing facilities (SNFs) are increasingly vital within the healthcare spectrum, particularly as the population of elderly patients continues its expansion. Definitive Healthcare’s data tracks over 20,000 skilled nursing facilities, providing a comprehensive view of this sector. Given that SNFs frequently deliver care to elderly patients and Medicare beneficiaries, examining the most prevalent diagnoses within these facilities offers critical insights into the healthcare needs of long-term care recipients. This analysis explores the most common diagnoses in SNFs, drawing from Medicare and commercial claims data to provide a detailed understanding of patient conditions in long-term care.
Top Common Diagnoses in Skilled Nursing Facilities
Analyzing claims data reveals the primary health concerns encountered in skilled nursing facilities. By understanding these common diagnoses, healthcare professionals and facilities can better prepare and tailor their services to meet patient needs effectively. The data presented below is sourced from medical claims clearinghouses in the United States and is current as of October 2023.
| Rank | ICD-10 code | ICD-10 description | % of claims |
|---|---|---|---|
| 1 | U071 | COVID-19 | 9.33% |
| 2 | G9341 | Metabolic encephalopathy | 3.30% |
| 3 | N390 | Urinary tract infection, site not specified | 2.92% |
| 4 | Z471 | Aftercare following joint replacement surgery | 1.81% |
| 5 | A419 | Sepsis, unspecified organism | 1.74% |
| 6 | J189 | Pneumonia, unspecified organism | 1.73% |
| 7 | G20 | Parkinson’s disease | 1.64% |
| 8 | Z4789 | Encounter for other orthopedic aftercare | 1.63% |
| 9 | G9340 | Encephalopathy, unspecified | 1.60% |
| 10 | J449 | Chronic obstructive pulmonary disease, unspecified | 1.54% |
| 11 | J9601 | Acute respiratory failure with hypoxia | 1.53% |
| 12 | I639 | Cerebral infarction, unspecified | 1.49% |
| 13 | F0390 | Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety | 1.07% |
| 14 | M6259 | Muscle wasting and atrophy, not elsewhere classified, multiple sites | 0.95% |
| 15 | I69354 | Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side | 0.92% |
| 16 | J441 | Chronic obstructive pulmonary disease with (acute) exacerbation | 0.91% |
| 17 | N179 | Acute kidney failure, unspecified | 0.87% |
| 18 | S72002D | Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing | 0.84% |
| 19 | S72001D | Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing | 0.84% |
| 20 | I69351 | Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side | 0.83% |
| 21 | Z48815 | Encounter for surgical aftercare following surgery on the digestive system | 0.82% |
| 22 | Z4781 | Encounter for orthopedic aftercare following surgical amputation | 0.77% |
| 23 | S72142D | Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing | 0.76% |
| 24 | I509 | Heart failure, unspecified | 0.74% |
| 25 | R278 | Other lack of coordination | 0.73% |
| 26 | S72141D | Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing | 0.71% |
| 27 | I4891 | Unspecified atrial fibrillation | 0.68% |
| 28 | I5033 | Acute on chronic diastolic (congestive) heart failure | 0.59% |
| 29 | J9621 | Acute and chronic respiratory failure with hypoxia | 0.59% |
| 30 | M6282 | Rhabdomyolysis | 0.58% |
| 31 | G309 | Alzheimer’s disease, unspecified | 0.56% |
| 32 | N186 | End stage renal disease | 0.54% |
| 33 | Z48812 | Encounter for surgical aftercare following surgery on the circulatory system | 0.53% |
| 34 | I214 | Non-ST elevation (NSTEMI) myocardial infarction | 0.52% |
| 35 | F0391 | Unspecified dementia, unspecified severity, with behavioral disturbance | 0.51% |
| 36 | E119 | Type 2 diabetes mellitus without complications | 0.47% |
| 37 | L03115 | Cellulitis of right lower limb | 0.46% |
| 38 | R55 | Syncope and collapse | 0.46% |
| 39 | L03116 | Cellulitis of left lower limb | 0.45% |
| 40 | I6930 | Unspecified sequelae of cerebral infarction | 0.42% |
| 41 | G35 | Multiple sclerosis | 0.42% |
| 42 | I2510 | Atherosclerotic heart disease of native coronary artery without angina pectoris | 0.40% |
| 43 | I5023 | Acute on chronic systolic (congestive) heart failure | 0.38% |
| 44 | I480 | Paroxysmal atrial fibrillation | 0.37% |
| 45 | J690 | Pneumonitis due to inhalation of food and vomit | 0.36% |
| 46 | D649 | Anemia, unspecified | 0.36% |
| 47 | I69398 | Other sequelae of cerebral infarction | 0.31% |
| 48 | S065X0D | Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter | 0.31% |
| 49 | S7291XD | Unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing | 0.30% |
| 50 | E871 | Hypo-osmolality and hyponatremia | 0.29% |
Figure 1: Analysis of claims data reveals the most common diagnoses in skilled nursing facilities as of October 2023.
COVID-19 stands out as the most frequent diagnosis in skilled nursing facilities, accounting for 9.33% of all claims. Long-term care facilities, including SNFs, were significantly impacted during the pandemic’s onset. Given that the patient demographic in SNFs is predominantly elderly, a large proportion falls into the high-risk category for COVID-19, contributing to its top ranking among diagnoses.
Following COVID-19, metabolic encephalopathy is the second most common diagnosis, representing 3.30% of SNF claims. This condition encompasses neurological disorders arising from systemic illnesses such as heart disease, diabetes, and respiratory or renal failure. The prevalence of metabolic encephalopathy underscores the complex health profiles of patients requiring skilled nursing care.
Urinary tract infections (UTIs) are the third most common diagnosis, comprising 2.92% of claims. UTIs are not only frequently observed in nursing homes but are also recognized as one of the most common healthcare-acquired infections. This highlights the ongoing need for robust infection control protocols within long-term care settings.
Beyond these top three, several other diagnostic categories are prevalent in SNFs. Respiratory illnesses such as pneumonia and chronic obstructive pulmonary disease (COPD), neurological disorders like dementia, and various orthopedic conditions related to post-surgical aftercare are also frequently diagnosed. These conditions collectively paint a picture of the diverse healthcare needs managed within skilled nursing facilities.
Understanding Skilled Nursing Facilities in Long Term Care
A skilled nursing facility (SNF) is an inpatient facility designed to provide either short-term or long-term rehabilitation services. These facilities are characterized by their capacity to offer 24-hour licensed medical support to patients who require transitional care. This care typically follows a hospital stay necessitated by illness, injury, or surgery.
SNFs primarily cater to elderly patients, and a significant majority are certified by Medicare. Medicare coverage extends up to 100 days in an SNF for eligible beneficiaries, although patients may incur out-of-pocket expenses for each day exceeding this limit.
Qualifying for Skilled Nursing Care
Specific criteria determine patient eligibility for skilled nursing care coverage under Medicare. Beneficiaries are generally covered if they meet the following conditions:
- Enrollment in Medicare Part A with available days in their benefit period.
- A formal admission to inpatient hospital care for at least three consecutive days.
- Entry into a Medicare-certified SNF within 30 days of hospital discharge, seeking care for the same condition treated during hospitalization.
- A physician’s determination that daily skilled care, delivered or supervised by skilled nursing or therapy staff, is medically necessary.
Patients qualifying for skilled nursing care can access a range of essential services within SNFs, including:
- Medication management to ensure accurate and timely administration.
- Assistance with activities of daily living (ADLs) such as bathing, dressing, and eating.
- Meal preparation and dietary counseling to meet specific nutritional needs.
- Wound care management to prevent infection and promote healing.
- Physical, occupational, and/or speech therapy to aid recovery and rehabilitation.
- Cardiac rehabilitation programs for patients recovering from heart conditions.
- Post-stroke rehabilitation services to help patients regain lost function.
SNFs vs. Other Long-Term Care Options
Distinguishing skilled nursing facilities from other types of long-term care options, such as assisted living facilities and nursing homes, is crucial. The primary distinction between SNFs and assisted living facilities lies in the level of care provided. SNFs are equipped to provide comprehensive medical care, whereas assisted living facilities focus more on personal care services within a residential, community-oriented setting. Residents of assisted living typically require less intensive clinical care compared to SNF patients, who need 24/7 medical attention or rehabilitation.
Skilled nursing facilities also differ from traditional nursing homes. Nursing homes often serve as permanent residences for individuals requiring continuous long-term care. In contrast, SNFs are designed as temporary residences for patients undergoing rehabilitation or skilled nursing care for a defined period, typically following a hospital stay. The care in SNFs is intended to be transitional, aimed at enabling patients to return to a lower level of care setting or to their homes.
Learn More
Understanding the common diagnoses and the role of skilled nursing facilities is essential for navigating the landscape of long-term care. For deeper insights into healthcare commercial intelligence, including detailed data on hospitals, physicians, and healthcare providers, explore Definitive Healthcare’s platform. Start a free trial today to access the latest healthcare commercial intelligence.
