PDPM: Snap Up This ICD-10-CM Knowledge for Your SNF

The Patient Driven Payment Model is bringing new importance to the ICD-10-CM code set for SNFs. Here’s where the diagnosis codes will come into play.

Get a Quick Overview of the PDPM

The Patient Driven Payment Model (PDPM) is a new case-mix classification system that will replace the Resource Utilization Group, Version IV (RUG-IV), effective Oct. 1, 2019. The PDPM will classify skilled nursing facility (SNF) patients in a Medicare Part A stay into payment groups as part of the SNF Prospective Payment System. RUG IV primarily uses therapy service volume as the basis for payment. The stated intent of PDPM is to classify patients into payment groups based largely on patient characteristics and conditions.

There are two ways that you’ll use ICD-10-CM codes under PDPM, according to the Patient-Driven Payment Model: Frequently Asked Questions document (available at the CMS PDPM site). Both are explained below.

Report the Primary Diagnosis for the SNF Stay

Under PDPM, providers will report on the Minimum Data Set (MDS) the patient’s primary diagnosis for the SNF stay. The FAQs state that CMS expects the principal diagnosis on the SNF claim to match the primary diagnosis in item I0020B, the new item being added to the MDS under PDDM as a space for the patient’s primary SNF diagnosis. But there won’t be a claims edit to enforce that match (according to the April 4, 2019, version of the FAQs).

CMS has mapped each primary diagnosis to a PDPM clinical category. The 10 PDPM clinical categories each represent groups of similar diagnosis codes. The categories play a role in the patient’s classification under the physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) components (these are three of the five case-mix adjusted components, along with a non-therapy ancillary services component and a nursing component).

Select Additional Diagnoses to Show Bigger Picture

You’ll also use ICD-10-CM codes to capture additional diagnoses and comorbidities because these may affect patient classification under the SLP component and the non-therapy ancillary (NTA) comorbidity score.

CMS will use the NTA comorbidity score to classify the patient into an NTA component payment group. Comorbidities linked to higher NTA costs have higher points. The score is the sum of the points associated with each comorbidity. Check section 3.3 of the FAQs to see the comorbidities used under the NTA component. As an example, Lung Transplant Status is assigned three points and the source is MDS Item I8000.

What Can You Do to Get Your SNF ICD-10-CM Ready?

Remember when ICD-10 replaced ICD-9? Just like that big transition, the current change requires preparation for the whole team.

Train clinicians and everyone concerned with the MDS, code assignment, and reimbursement on how to locate ICD-10-CM codes and the importance of selecting complete, accurate codes based on the documentation.
To speed the process of pinpointing codes, consider getting SNF ICD-10-CM cheat sheets that you can place in convenient locations.
Review the “PDPM ICD-10 Mappings” file available at that same CMS PDPM site linked in the overview section above. Look under PDPM Resources near the bottom of that page to access the file, which contains the ICD-10-CM to Clinical Category Mapping, SLP Comorbidity to ICD-10-CM Mapping, and NTA Comorbidity to ICD-10-CM Mapping.