Why April 1st Medicare Part B Changes Demand Immediate Coding Review
Beginning April 1, 2025, Medicare Part B quietly implemented a significant update that may already be impacting skilled nursing facility (SNF) claims across the country. The list of unacceptable principal diagnoses has expanded and now includes more ICD-10 codes tied to unspecified dementia and dementia in other diseases classified elsewhere. This is a shift that could lead to increased Part B denials if not addressed promptly.
If your billing teams or software haven’t caught up, your facility may already be at risk for increased claim rejections or delays.
What Changed?
CMS has added several dementia-related ICD-10 codes to the list of diagnoses no longer accepted as principal diagnoses under Medicare Part B. These include:
- F03.90 – Unspecified dementia without behavioral disturbance
- F03.91 – Unspecified dementia with behavioral disturbance
- Other dementia codes classified under F02 and F03 categories, especially when paired with vague or unrelated secondary codes
These codes, while clinically accurate in many settings, cannot stand alone as the principal diagnosis on Medicare Part B claims.
CMS’s Rationale: These codes lack the specificity required to justify the skilled level of care under the PDPM model, especially when a more direct underlying condition (e.g., Alzheimer’s disease or Parkinson’s disease) should be driving the skilled need.
For a full list of these codes, click here.
Why This Matters
If your team continues to use these codes as the primary diagnosis:
- Claims may be rejected, slowing reimbursement.
- Your facility could see a reduction in cash flow or develop a pattern of non-compliance, which could trigger unnecessary audits, especially if used in large volume.
What You Should Do Now
- Review Current Coding Practices
Audit how dementia is currently being coded in your assessments and claims. Pull a recent sample of admissions and discharges and identify any use of newly unacceptable ICD-10 codes as primary diagnoses. - Educate Interdisciplinary Teams
Ensure MDS coordinators and billing departments all understand these coding changes. Dementia may still appear on the claim, but only in the appropriate sequencing. - Update Your Software or Mapping Tools
Make sure EMR systems, diagnosis selection drop-downs, and auto-mapping tools are current with CMS’s updated ICD-10 PDPM Unacceptable Codes list as of April 1.
Call to Action: Protect Your Revenue & Compliance
Now is the time to proactively safeguard your claims. Even if your Part B denials haven’t started yet, they may be coming if outdated codes are still in use.
Review your facility’s coding protocols today and retrain your teams to code dementia with greater specificity. Accurate coding isn’t just a best practice; it’s essential for both compliance and timely reimbursement.
Written by:
Sheena Mattingly M.S. CCC-SLP RAC-CT, EVP of Quality & Compliance | Healthcare Therapy Services