PDPM Reimbursement Model Top 5 Opportunities PDPM is an improved payment system used by the CMS to calculate reimbursements for skilled nursing facilities. 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. We earn 1 NTA point for second or third degree burn coded in M1040F. This revised payment methodology is driven by the patient's clinical characteristics rather than the . Due to the public health emergency (PHE), the data doesn't show a major joint . Quickly identify associated clinical categories. Clinical Mapping Under PDPM. Before discussing PDPM clinical categories, it is worth understanding how PDPM works. The current ICD-10 clinical category mapping doesn't provide an option of a major surgical procedure in the prior inpatient stay for numerous cancer diagnoses. All information regarding PDPM is subject to change pending final rulemaking. Before that, we had RUG scores. Secondly, active diagnoses coded . Diabetes Mellitus, hemiplegia, Parkinson's. etc. For these codes, a patient may be categorized into a The Medicare Patient-Driven Payment Model (PDPM) is a major overhaul to the current skilled nursing facility (SNF) prospective payment system (PPS). The exception is when the the functional score is maxed out at 24. (click to enlarge) Remember, the PT/OT pay bucket is generally greater as the patient has *more* function. Certain codes entered in I0020B (primary reason for skilled stay) will map to "return to provider". There is a CMS spreadsheet that is a crosswalk from ICD-10 codes to the clinical categories for PT/OT and SLP. 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. I0020B diagnosis: Default primary diagnosis clinical category: Some ICD-10-CM codes can map to a different clinical category from the default depending on a patient's prior inpatient procedure history. In the FY 2020 ICD-10 to clinical category mapping, the M48.00 through M48.08 spinal stenosis codes have a default clinical category mapping of "Non-Surgical Orthopedic/Musculoskeletal" and no surgical option, which does not allow for coding in cases where . Now you can: Navigate through over 65,000 ICD-10 codes. Master PDPM diagnoses with this powerful free tool. tab, ICD 10 codes have now been mapped appropriately. 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. 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. 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. 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. PDPM Resident Classification Workbook_Betty W - Page 7: 3 Best practice is for the Interdisciplinary Team . While RUG-IV categorized patients into a single, volume-driven case-mix group, PDPM focuses on the . 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: primary diagnosis as recorded in MDS item I0020B to the 10 PDPM primary diagnosis clinical categories. PDPM classification . It is designed to address concerns that a payment system based on the volume of services provided creates inappropriate financial incentives. 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 Step 8 - Identify the PDPM SLP Clinical Category . (10/1/2019) J2300J5000 Clinical Category-MDS 3.0: Section J MDS Changes: Patient SurgicalCategories 50 Item Surgical ProcedureCategory Item Surgical ProcedureCategory Non-Surgical Orthopedic/Musculoskeletal. To help you prepare for PDPM, we've launched a FREE version of our powerful PDPM Diagnosis Explorer tool. 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. The 25 PDPM RUGs reduces the number of end-splits determined by ADL calculations. 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. 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 . However, there were no significant changes in . Some ICD-10-CM codes can map to a different clinical category from the default depending on a resident's prior inpatient procedure history. CLINICAL STRATEGIES . to classify patients into a PDPM clinical category, which is then used as part of the PT, OT, and SLP case . 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. PDPM Profiler . 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. Acute Neurologic. If the resident receives TPN while in the SNF, you will see higher NTA and . Nursing Rehab. 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 . In part three of our six part series we review the nursing category of PDPM. I8000 Active Diagnosis is a field that under PDPM will require careful attention to detail. CMS believes that PDPM appropriately assigns payment which reflects a direct correlation between independence and PT/OT utilization; essentially, PT and OT utilization . HIPPS Coding for PDPM. 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. PDPM: FROM ADMISSION TO DISCHARGE MELODY SCHROCK, RN, BSN, RAC-CT QIPMO CLINICAL EDUCATOR Webinar 9/18/19 OBJECTIVES Identify PT/OT components of PDPM Apply PDPM knowledge to accurately code a clinical resident scenario. 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. 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. 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. 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 . 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. Physician Supportive Diagnosis of Active condition within 60 day 16. . So they need to be very, very aware of the fact of what that primary diagnosis code is, okay . This means, however, that accurate recording of the diagnoses, and documentation supporting the relevance of the . Due to the public health emergency (PHE), the data doesn't show a major joint . Medical Management. 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. MDS Nurses should use this tool to ensure transferred residents do not receive a "return to provider" ICD-10 Code. This would fall under the Major Joint Replacement or Spinal Surgery PDPM Clinical Category. 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). As discussed in Section V.D.3.b, the proposed PDPM would use ICD-10 diagnosis and procedural codes in order to ify SNF residents into one of ten PDPM Clinical Categories, which would then be used to further ify the resident for payment purposes under PDPM. . . When a code is returned to a provider, the provider is to select an appropriate ICD-10-CM diagnosis code from the SNF PDPM Clinical Category Mapping available at CMS' website. CMS has finalized several changes to the PDPM ICD-10 code mappings and lists. The Patient Driven Payment Model (PDPM) was implemented in October 2019 to reimburse skilled nursing facilities (SNFs) based on Medicare patients' clinical and functional characteristics rather than the volume of services provided. 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. Identify row in the CMS ICD-10 Clinical Category Crosswalk Excel file that corresponds to the Primary reason for the SNF Stay ICD -10- . 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. While RUG-IV categorized patients into a single, volume-driven case-mix group, PDPM focuses on the . For instance, if there were specific, related surgical procedures performed in the hospital . However, there were no significant changes in . 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. 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. Resources: FY 2019 SNF PPS Proposed Rulemaking and CMS draft PDPM Calculation Worksheet for SNFs. This site includes a variety of educational . 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. 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 If the resident receives TPN while in the SNF, you will see higher NTA and . PDPM GROUPER Logic (SAS) ICD-10 Clinical Category Crosswalk *ICD-10 NTA Comorbidity Crosswalk (*disabled as of 4/4/19, combined into Clinical The Patient Driven Payment Model (PDPM) was implemented in October 2019 to reimburse skilled nursing facilities (SNFs) based on Medicare patients' clinical and functional characteristics rather than the volume of services provided. Diabetes Mellitus, hemiplegia, Parkinson's. etc. During this webinar we demonstrate how the MDS will be used to determine the nursing category and how it differs from the . Unlike the RUG IV system, every resident will be assigned a PDPM nursing clinical category as part of the overall PDPM rate. When PDPM took effect on October 1, 2019, skilled nursing operators had to make a number of adjustments around their day-to-day operations. Skilled Nursing Facility (SNF) patients are classified into Health Insurance Prospective Payment System (HIPPS) payment groups, based on the MDS response. Refer to the CMS PDPM ICD-10 Clinical Category Crosswalk to classify SNF residents into one of ten PDPM Clinical Categories. PDPM will be the law of the land come October 1, 2019. For these codes, a resident may be categorized into a . Major Joint Replacement or Spinal Surgery. Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Pulmonary. . The following changes will be effective October 1, 2020: Certain Cancer ICD-10 Codes- Previously specific cancer diagnoses that could require a major surgical procedure did not include an option to map into a surgical category.CMS has added surgical clinical category options of "Maybe Eligible for the Non-Orthopedic Surgery Category" or "Maybe Eligible for One of the Two Orthopedic . 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. Effective October 1, 2019, the Patient Driven Payment Model (PDPM) will improve payments made under the SNF Prospective Payment System (PPS). Explore NTA and SLP comorbidities for . 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. This single primary diagnosis will then map to 1 of 10 PDPM clinical categories which directly impacts reimbursement. mix classification groups by placing the patient into a Clinical Category. First, the SNF is required to report on the MDS the patient's primary diagnosis for the skilled stay. 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. 3. TM TN TO TP . PDPM has clinical categories as well but t higher functional scores don't always mean higher CMI. lack certainty and specificity required to properly categorize a resident under PDPM or the underlying condition cannot be the main reason of care in SNFs. Next, calculate the PT/OT function score. 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); item I0020B to the 10 PDPM primary diagnosis clinical categories. PDPM does not completely do away with the RUGS IV methodology. Obtain surgical history records. Example 2: A patient sustained a right displaced intertrochanteric fracture of the . Impact of ICD-10 on PDPM and how it drives the 10 "Clinical Categories". Consider these top 10 steps to an effective PDPM pre-5 Day MDS chart review process: Primary Diagnosis & Surgical Procedure. We know PDPM will be a big shift, that's why we've created this mapping infographic and an entire PDPM Resource Center to house . It is designed to address concerns that a payment system based on the volume of services provided creates inappropriate financial incentives. 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); 3. If a "return to provider" code is used in I0020B of the MDS, the claim will . Are "return to provider" codes allowed? 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. The PDPM ICD-10 CM Mapping Tool is an excellent resource for MDS nurses looking to code PDPM correctly. This mapping tool crosswalks ICD-10-CM codes to PDPM clinical categories and is updated annually. As mentioned previously, PDPM begins with the Part A patient being classified into a clinical category based on the diagnosis codes appearing in I8000. 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. I0020B Diagnosis: Default Principal Diagnosis Clinical Category: Specific examples of the 27,854 codes that will be rejected October 1, 2019. . These effects differed by categories of clinical diagnoses. Education and training now is critical. See the chart below. All ICD-10-CM diagnosis codes have been assigned to a default clinical category shown in column C in the diagnosis clinical category file. A functional score of 24 only has higher within tier . 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. RCS-1 was a precursor to the PDPM model . . 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. 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 . Resources: FY 2019 SNF PPS Final Rulemaking, CMS Fact sheet: PDPM Patient Classification, and CMS draft PDPM Calculation Worksheet for SNFs.