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This single primary diagnosis will then map to 1 of 10 PDPM clinical categories which directly impacts reimbursement. Before that, we had RUG scores. 3. •New MDS item I0020B is used to "map" to one of the PDPM clinical categories •Section J (Surgical Procedures) is used to further adjust clinical classifications, if applicable (must occur during the current hospital stay) •Note: Under the cms.gov PDPM resources is a PDPM ICD-10 mapping tool (revision 8/30/19) MDSItem/Claim Condition/Extensive Service Points SNF Claim HIV/AIDS 8 H0100C Bladder and Bowel Appliance: Ostomy 1 H0100D Bladder and Bowel Appliance: Intermittent Catheterization 1 K0510A2, K0710A2 rq wkh sulpdu\ 61) gldjqrvlv pd\ eh dgmxvwhg lq fdvhv zkhuh wkh sdwlhqw uhfhlyhg d vxujlfdo lqwhuyhqwlrq gxulqj wkh suhfhglqj krvslwdo vwd\ dvvrfldwhg zlwk wkdw gldjqrvlv 7khvh vxujlfdo The Medicare Patient-Driven Payment Model (PDPM) is a major overhaul to the current skilled nursing facility (SNF) prospective payment system (PPS). One was increasing their attention on non-therapy ancillary services, or NTA, which is one of five components that determine reimbursement per patient day. (click to enlarge) Remember, the PT/OT pay bucket is generally greater as the patient has *more* function. The exception is when the the functional score is maxed out at 24. CMS has mapped each primary diagnosis to one of ten PDPM clinical categories based on the cost of care and services for managing the condition. The reason for the skilled stay must be discussed immediately upon admission and there needs to be a common understanding between billing, therapy, and nursing on what the primary . So they need to be very, very aware of the fact of what that primary diagnosis code is, okay . The 25 PDPM RUGs reduces the number of end-splits determined by ADL calculations. RCS-1 was a precursor to the PDPM model . Unlike the RUG IV system, every resident will be assigned a PDPM nursing clinical category as part of the overall PDPM rate. However, it'll be up to the provider to have a thorough understanding of the ICD-10 system to capture the ICD-10 code that supports the residents' qualifying stay as well as . Cancer. We earn 1 NTA point for second or third degree burn coded in M1040F. For these codes, a resident may be categorized into a . Resources: FY 2019 SNF PPS Final Rulemaking, CMS Fact sheet: PDPM Patient Classification, and CMS draft PDPM Calculation Worksheet for SNFs. As mentioned previously, PDPM begins with the Part A patient being classified into a clinical category based on the diagnosis codes appearing in I8000. categories or who would meet the criteria of Behavior Symptoms and Cognition Performance but have a Function Score less than 11) Depression Yes Yes Yes Yes Yes Yes Yes Function Score o- 14 o- 14 o- 14 6- 14 6 14 6- 14 6-14 6-14 15-16 6-14 Nursing Case Mix Group ES3 ES2 ESI HDE2 HDEI H 8C2 LDE2 LDEI LBCI CDE2 CDEI cac2 CA2 cacl CAI 8AB2 PDE2 PDEI Nursing Rehab. The PDPM Calculator helps you understand how changes in Default Clinical Category, Section GG, Speech and Language Pathology, Non-Therapy Ancillaries and Nursing Categories will change your PDPM categorization AND pay. Explore NTA and SLP comorbidities for . Section GG of the MDS will be used to determine the Function Score versus section G that is currently used for the RUG-IV PPS System Activities of Daily Living (ADL) Score. item I0020B to the 10 PDPM primary diagnosis clinical categories. SNF reimbursement under PDPM is based in large part on diagnosis - and, that's a good thing! The challenge for nurses under PDPM will be to make sure that the daily documentation truly supports the need for skilled care in a SNF, and that the patient characteristics are still documented as active. Step 8 - Identify the PDPM SLP Clinical Category . TM TN TO TP . CMS has finalized several changes to the PDPM ICD-10 code mappings and lists. CLINICAL STRATEGIES PDPM Calculation Worksheet for SNFs 1 PAYMENT COMPONENT: PT, OT, AND SLP Determine patient's Principal diagnosis clinical category using ICD-10-CM code recorded in MDS items I0020B. No clinical variables used. Master PDPM diagnoses with this powerful free tool. 2. SNF PDPM ICD-10 Diagnosis and Procedural Code Crosswalk. I0020B Diagnosis: Default Principal Diagnosis Clinical Category: Get reimbursed for hospital-administered total parenteral nutrition (TPN) In PDPM, TPN will impact the non-therapy ancillary (NTA) case-mix component, not just the nursing component which was the only category linked to TPN reimbursement in RUG-IV, says Benbow. One of the key drivers of PDPM reimbursement is the clinical category the patient is assigned to based on the principal diagnosis or reason for the skilled stay. This means, however, that accurate recording of the diagnoses, and documentation supporting the relevance of the . CMS notes that in July 2018, PDPM was finalized and was implemented on October 1, 2019. All urban and rural areas are included. This revised payment methodology is driven by the patient's clinical characteristics rather than the . Resources: FY 2019 SNF PPS Proposed Rulemaking and CMS draft PDPM Calculation Worksheet for SNFs. • Impact of ICD-10 on PDPM and how it drives the 10 "Clinical Categories". Refer to the CMS PDPM ICD-10 Clinical Category Crosswalk to classify SNF residents into one of ten PDPM Clinical Categories. First, the SNF is required to report on the MDS the patient's primary diagnosis for the skilled stay. one of the first drivers and coming up with the score is the primary diagnosis that the resident gets that gives them a clinical category, which kind of starts off the whole thing. PDPM will be the law of the land come October 1, 2019. Once the clinical category is identified by the diagnosis code at I0200B, the next step for the PT and OT components is to calculate the residents Function Score. Clinical Category PT and OT Case-Mix Group GG Function Score NOTE: This document is intended to aid members in their review of the Patient-Driven Payment Model. If a "return to provider" code is used in I0020B of the MDS, the claim will . Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Pulmonary. Identify row in the CMS ICD-10 Clinical Category Crosswalk Excel file that corresponds to the Primary reason for the SNF Stay ICD -10- . relevant to classify the patient into a PDPM clinical category, CMS is adding new items in Section J of the MDS. • SNF patients are first classified into a clinical category based on the primary diagnosis for the SNF stay • To determine a resident's clinical category, use the clinical map and follow the instructions: ICD-10 clinical mapping available on the PDPM webpage PDPM Clinical Categories Confidential, unpublished property of Cigna. PDPM got started on October 1, 2019. The shift from the RUG-IV case-mix model to a patient driven payment model is marked by goals to: Improve payment accuracy and ensure appropriate treatment by focusing on the individual patient, rather than volume of services provided. PDPM has clinical categories as well but t higher functional scores don't always mean higher CMI. The Nursing Component uses a modified non-therapy RUG calculation that places residents into one of 25 categories instead of the previous 43 nursing categories under the 66 Grouper. Explore the impact of proper clinical documentation on the calculation of the various components in the PDPM rate. Non-Orthopedic Surgery. PDPM classification . Before discussing PDPM clinical categories, it is worth understanding how PDPM works. Mapping to the PDPM clinical category will come from new items set, I0020B (What's the main reason this person is being admitted to the SNF?) Due to the public health emergency (PHE), the data doesn't show a major joint . This would fall under the Major Joint Replacement or Spinal Surgery PDPM Clinical Category. ICD-10-CM AND THE PDPM Nursing Utilizes RUG categories however the number of terminal categories has been reduced from 43 to 21 Some diagnoses still impact the Nursing category assignment, e.g. The transition to PDPM on October 1 brought forth a whole new reimbursement system centered around primary clinical characteristics of the patient that is dependent on five categories: PT, OT, SLP, NTA and Nursing. In July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay. coupled with possible responses to new item set J2100-J5000 (Surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission). For example, in the prior versions, there was an incomplete list of dx and some dx that should have mapped to possible surgical procedures did not. In part three of our six part series we review the nursing category of PDPM. With the major shift from RUG-IV to PDPM, our post-acute care experts have received a multitude of questions revolving around diagnosis coding and how it greatly affects a SNF's . . Effective October 1, 2019, the Patient Driven Payment Model (PDPM) will improve payments made under the SNF Prospective Payment System (PPS). . See the chart below. Activities > =2, at least 6 days a week Passive or Active ROM, amputation care, splint care, Training in dressing or grooming, eating or swallowing, transfer, bed mobility or walking, communication, scheduled toileting program or bladder retraining Restorative Nursing Programs: Begin with a review of hospital documentation related to the primary diagnosis selection for the skilled stay and a check to ensure diagnosis mapping to a PDPM clinical category. . CMS has mapped each primary diagnosis to one of ten PDPM clinical categories based on the cost of care and services for managing the condition. Skilled Nursing Facility (SNF) patients are classified into Health Insurance Prospective Payment System (HIPPS) payment groups, based on the MDS response. The PDPM updates were additions and deletions of ICD-10 codes used to map the primary reason for skilled care to the appropriate PDPM clinical category. PDPM Resident Classification Workbook_Betty W - Page 7: The reason for skilled stay will be the ICD-10 code that MDS uses in I8000 and this Clinical Category PDPM Therapy Function Score OT Case-Mix Group OT Case-Mix Index Major Joint Replacement or Spinal Surgery 0-5 TA 1.49 Major Joint Replacement or Spinal Surgery 6-9 TB 1.63 Major Joint Replacement or Spinal Surgery 10-23 TC 1.68 Major Joint Replacement or Spinal Surgery 24 TD 1.53 Other Orthopedic 0-5 TE 1.41 Other Orthopedic 6 . Answer: This statement holds true for the Major Joint Replacement or Spinal Surgery category, however, a score of 24 for any other Collapsed Clinical Category Group, will result in LESS reimbursement for the PT & OT Case-mix. This process is further discussed in the FY 2019 SNF PPS NPRM. HIPPS Coding for PDPM. This site includes a variety of educational . ICD-10-CM AND THE PDPM Nursing Utilizes RUG categories however the number of terminal categories has been reduced from 43 to 21 Some diagnoses still impact the Nursing category assignment, e.g. primary diagnosis as recorded in MDS item I0020B to the 10 PDPM primary diagnosis clinical categories. . An example of this is a patient who has a primary diagnosis that supports the Medical Management clinical category. Non-Surgical Orthopedic/Musculoskeletal. • Some ICD-10-CM codes can map to a different clinical category from the default depending on a resident's prior inpatient procedure history. Also, any surgical procedures must have occurred in the last 30 days, and during the inpatient stay that immediately preceded the resident's Part A admission. Overview. (10/1/2019) • J2300‐J5000 Clinical Category-MDS 3.0: Section J MDS Changes: Patient SurgicalCategories 50 Item Surgical ProcedureCategory Item Surgical ProcedureCategory Physician Supportive Diagnosis of Active condition within 60 day 16. This clinical classification, based on the primary SNF diagnosis, may be adjusted in cases where the patient received a surgical intervention during the preceding hospital stay associated with that diagnosis. As a reminder, PDPM utilizes International Classification of Diseases, Version 10 (ICD-10) codes in several ways, including assigning patients to clinical categories used for categorization under . PDPM PATIENT CLASSIFICATION Under PDPM, residents are classified into a group for ea ch of the five case-mix adjusted components: PT, OT, SLP, Nursing and NTA Each component utilizes different criteria as the basis for patient classification: PT: Clinical Category & Functional Score OT: Clinical Category & Functional Score This updated fact sheet explains, "ICD-10-CM codes, coded on the MDS 3.0 in Item I0020B, are mapped to a PDPM clinical category. Clinical PT Category PT and OT Case-Mix Group GG Function Score NOTE: This document is intended to aid members in their review of the Patient-Driven Payment Model. . Major Joint Replacement or Spinal Surgery. to classify patients into a PDPM clinical category, which is then used as part of the PT, OT, and SLP case . We earn 1 NTA point and qualify for Nursing Category Special Care Low for a Stage IV Pressure Ulcer when coded in M0300. It is designed to address concerns that a payment system based on the volume of services provided creates inappropriate financial incentives. During this webinar we demonstrate how the MDS will be used to determine the nursing category and how it differs from the . These effects differed by categories of clinical diagnoses. CLINICAL STRATEGIES . PDPM Function Score YES 14 or less 15 or 16 Is the resident coded for: Pneumonia (I2000); Hemiplegia/hemiparesis (I4900 & GG <=11); Open lesions with any selected skin treatments or surgical wounds (M1040D,E); Burns (M1040F); Chemo while resident (O0100A2); Oxygen Therapy while resident (O0100C2); Acute Neurologic. A functional score of 24 only has higher within tier . PDPM is an improved payment system used by the CMS to calculate reimbursements for skilled nursing facilities. Due to the public health emergency (PHE), the data doesn't show a major joint . must Map to PDPM Clinical Category SLP Co-morbidities must Map to SLP Category NTA -28 of the 50 NTA Items Require an ICD-10 Dx that maps to a NTA qualifying Diagnosis. Obtain surgical history records. However, there were no significant changes in . There is a CMS spreadsheet that is a crosswalk from ICD-10 codes to the clinical categories for PT/OT and SLP. If the resident receives TPN while in the SNF, you will see higher NTA and . PDPM, unlike RUG-IV, is a Case-Mix Group (CMG) reimbursement method that focuses more on clinically relevant factors and not just volume-based services. MDS Nurses should use this tool to ensure transferred residents do not receive a "return to provider" ICD-10 Code. For instance, if there were specific, related surgical procedures performed in the hospital . Each primary diagnosis is mapped to one of ten PDPM clinical categories, representing groups of similar diagnosis codes, which is then used as part of the patient's classification under the PT, OT, and SLP components. The shift from the RUG-IV case-mix model to a patient driven payment model is marked by goals to: Improve payment accuracy and ensure appropriate treatment by focusing on the individual patient, rather than volume of services provided. Explore the impact of proper clinical documentation on the calculation of the various components in the PDPM rate. There are two ways in which diagnosis codes are used under PDPM. PDPM Reimbursement Model Top 5 Opportunities CMS believes that PDPM appropriately assigns payment which reflects a direct correlation between independence and PT/OT utilization; essentially, PT and OT utilization . PDPM GROUPER Logic (SAS) ICD-10 Clinical Category Crosswalk *ICD-10 NTA Comorbidity Crosswalk (*disabled as of 4/4/19, combined into Clinical Additionally, CMS has made available a PDPM Clinical Category Mapping tool, which helps providers match the ICD-10-PCS code to the clinical categories outlined above. Now you can: Navigate through over 65,000 ICD-10 codes. PDPM Function Score YES 14 or less 15 or 16 Is the resident coded for: Pneumonia (I2000); Hemiplegia/hemiparesis (I4900 & GG <=11); Open lesions with any selected skin treatments or surgical wounds (M1040D,E); Burns (M1040F); Chemo while resident (O0100A2); Oxygen Therapy while resident (O0100C2); I8000 Active Diagnosis is a field that under PDPM will require careful attention to detail. The staff would review the information sent by the preceding hospital stay to identify any procedures defined in these surgical clinical categories.

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