Why use a PDPM mapping tool? Well, since the introduction of the Patient-Driven Payment Model (PDPM) by the Centers for Medicare and Medicaid (CMS) in October 2019, significant changes have been made to how Skilled Nursing Facilities (SNFs) classify residents into clinical categories when calculating PDPM reimbursement for Medicare Part A stays.
Unlike the previous RUG-IV case-mix model, which grouped nursing home residents according to the volume of rehabilitative services, PDPM focuses on a resident’s individual care needs and health concerns. Under PDPM, therapy minutes are removed from the payment calculations and replaced with the anticipated resources needed during a resident’s stay.
Each resident is assessed by an MDS nurse or coordinator who assigns a PDPM case-mix classification calculated from the daily reimbursement rate. The MDS nurse will conduct a series of assessments, like the Minimum Data Set (MDS) 3.0, to determine an appropriate care plan via the facility’s care plan software.
By developing the new payment system, the CMS has placed more financial accountability on healthcare providers to assess and provide legitimate patient analysis for each resident properly. This allows caregivers to make more informed care decisions and provide better resident care.
Naturally, though, some caregivers have difficulty independently calculating their PDPM scores. This has resulted in leading long term care software vendors, like NetSolutions by Experience Care, creating PDPM mapping tools to assist with calculating PDPM reimbursements.
What is a PDPM Mapping Tool?
A PDPM mapping tool helps facilities maximize PDPM reimbursement by determining accurate ICD-10 (International Classification of Disease, 10th Revision) codes, which are crucial for PDPM reimbursement.
To qualify for PDPM reimbursements, facilities must identify and verify ICD-10 codes associated with clinical categories. A single ICD code directly impacts PDPM reimbursement for the Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) case-mix classification groups by placing the resident into a clinical category.
The fact that there are thousands of ICD-10 codes makes the process of identifying and verifying them quite difficult and time consuming, creating the need for an innovative PDPM mapping tool, like the new PDPM HIPPS Projector.
This helpful tool allows MDS nurses and coordinators to highlight essential resident data and easily capture diagnosis codes for clarification. The PDPM mapping tool is designed to minimize evaluation time through automated processes, allowing MDS nurses to answer a set of PT/OT clinical questions for primary diagnosis with multiple choice answers, thus speeding up the process.
Once an MDS nurse has responded to a question, the PDPM mapping tool automatically saves the answers before generating a personalized PDPM HIPPS score for each resident. In using this particular PDPM mapping tool, facilities can rest easy knowing that there is a way to double-check long-winded assessment processes, like the Interim Payment Assessment (IPA), PPS Five-Day assessment, and the MDS, in order to ensure accurate PDPM reimbursement rates.
Understanding the PDPM Diagnosis List
The PDPM diagnosis list is coded according to the Five-Day and MDS assessments, which determine the reimbursements for a Medicare Part A stay. The CMS has mapped out each primary diagnosis into ten PDPM clinical categories that are based on the cost of care and anticipated services required to treat each condition.
These clinical categories are PT, OT, and SLP. The categories impact a resident’s case-mix classification. Facilities must ensure efficient processes are in place when selecting the primary diagnosis. Additionally, all diagnoses must adhere to the RAI Manual and the Coding Guidelines. Failure to do so can result in medical errors, inaccurate reimbursement payments, and adverse resident outcomes.
Facilities must also ensure accurate documentation to support all primary and active diagnoses coding. Long term care providers generally use a primary diagnosis for billing purposes so that facilities can inform the payer how much the facility is owed after a medical claim is submitted. Therefore, it plays a critical role in determining how much reimbursement the long term care facility receives for care services provided.
An active or principal diagnosis determines a resident’s underlying symptoms after admission into a hospital and after a physician completes the necessary tests and examinations. It relates to the resident’s functional, cognitive, and behavioral status, medical treatments, and nursing monitoring.
Modern long term care facilities will have a practical nursing home software system that enables caregivers to document care more effectively, enabling the accurate capture of clinical and financial data. Furthermore, facilities can also turn to a PDPM mapping tool to determine the ICD-10-CM diagnosis codes and ensure timely and proper reimbursements.
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7 Tips for Using a PDPM Diagnosis Mapping Tool to Determine the PDPM Primary Diagnosis
Determining the PDPM primary diagnosis is not always easy, especially if there is more than one diagnosis that meets the same criteria for the primary diagnosis. In such cases, the Interdisciplinary Team (IDT) must determine the code for the correct payment categories and the skilled nursing services provided to residents.
For this reason, long term care facilities must have an effective long term care software system that can select the primary diagnosis while ensuring all documentation supports the coding for all active diagnoses.
When the IDT is determining the diagnosis, there are a few helpful pointers they can use to make their job much easier:
- Before assigning the primary diagnosis, refer to the Clinical Category Crosswalk Tool, another practical PDPM diagnosis mapping tool that ensures the diagnosis is valid and not labeled “Return to Provider,” which indicates that the claim has incomplete, incorrect, or missing information. In such cases, this claim will be returned to the facility for further corrections and clarification.
- Ensure the primary diagnosis states why a resident was admitted into a nursing facility and what care is needed. Sometimes, a resident may have multiple diagnoses. Therefore, it is best practice to use a PDPM mapping tool to determine the diagnosis codes and a long term care EHR software system to document their care.
- Ensure the physician and the IDT communicate with each other, so all critical documentation and detailed primary diagnoses are appropriately recorded and adhere to the PDPM ICD-10-CM Mappings.
- Be vigilant when checking the PDPM diagnosis list, as sometimes an SNFs primary diagnosis may differ from the hospital’s primary diagnosis.
- Assess the facility’s processes and the level of staff competency when determining the correct diagnosis codes. If staff members lack the knowledge to determine the correct diagnosis codes, the facility should provide PDPM training courses to upskill their staff.
- Provide ongoing diagnosis training for MDS nurses, coordinators, and other staff members to ensure all personnel is up-to-date with the CMS’ latest regulations.
- Conduct regular Quality Assurance (QA) audits to ensure coding accuracy and proper documentation practices are observed.
The key to accurate PDPM reimbursements is understanding the clinical decision-making process when selecting a primary diagnosis over another. Caregivers should use a PDPM mapping tool to aid the process when in doubt.
So Why Use a PDPM Mapping Tool?
As discussed earlier, understanding clinical category mapping and ICD codes can be long and arduous. Depending on the assessment type and the entered answers, there are thousands of possible codes, which makes the job of an MDS nurse all the more difficult. Using a PDPM mapping tool, like the PDPM HIPPS Projector, is a practical and efficient way to improve the accuracy of HIPPS scores while dramatically reducing the processing time to determine the scores.
A caregiver who makes effective use of a PDPM mapping tool will be able to complete the task within ten minutes and be assured that their PDPM reimbursements cover the cost of care for all the services provided to a resident while at the facility.
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