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The Patient-Driven Payment Model (PDPM) is an overhaul to the CMS’ skilled nursing facility (SNF) Prospective Payment System (PPS), which came into effect on October 1, 2019.

The Patient-Driven Payment Model essentially changed how SNF services are reimbursed for the services they provide. Under the new PDPM clinical category mapping system, facilities use six components, including case-mix adjusted components, to determine what payment is needed. These PDPM clinical categories are mapped using ICD-10-CM codes, a globally recognized diagnostic tool used for epidemiology, health management, and clinical purposes. 

The mapping of ICD-10-CM codes plays an essential role in PDPM clinical categories and how PDPM reimbursement is determined.The five case-mix adjusted components used in PDPM clinical category mapping are:

PDPM clinical category mapping used by nurse to classify resident.
The mapping of ICD-10-CM codes plays an essential role in PDPM clinical categories and how PDPM reimbursement is determined.
  • Physical Therapy (PT): These are ICD-10-CM codes that map to PDPM PT clinical categories and include—but are not limited to—codes that describe impairments in body movement and control, such as gait and balance disorders.
  • Occupational Therapy (OT): These ICD-10-CM codes map out PDPM OT clinical categories. They are codes that describe impairments in activities of daily living, such as dressing and grooming.
  • Speech-Language Pathology (SLP): These are ICD-10-CM codes that describe impairments in communication, such as aphasia.
  • Non-Therapy Ancillary (NTA): These ICD-10-CM codes map to PDPM NTA clinical categories. They are codes that describe ancillary services required for patient care, such as social work services.
  • Nursing component: These ICD-10-CM codes match with PDPM nursing clinical categories that include, but are not limited to, codes that describe nursing diagnoses, such as pressure ulcers.

The sixth PDPM clinical category is a non-case-mix adjusted component that covers unvarying resources (laundry, room cleaning), regardless of patient or resident characteristics. It is essential that facilities understand PDPM clinical category mapping because it determines how PDPM reimbursement rates are decided. PDPM reimbursement is linked to the PDPM clinical category and a patient’s ICD-10-CM code maps. MDS nurses and other staff in charge of reimbursements would benefit from knowing that the PDPM clinical category with the highest reimbursement rate is PT, followed by OT, SLP, NTA, and nursing.

PDPM Mapping Tool: 5 Best Practices

Long term care staff can make use of a PDPM mapping tool, such as the Fiscal Year PDPM ICD-10 Mappings provided by the CMS. The PDPM ICD-10 Mappings tool is a downloadable document that crosswalks ICD-10-CM codes to PDPM clinical categories for the current fiscal year. PDPM clinical category mapping is not static and is updated annually.

It is worth noting that there are three typical outcomes that occur when selecting resident ICD-10-CM codes in a long term care facility:

Nurse caring for a nursing home resident.
ICD-10-CM codes provided by the provider indicate why the patient needs skilled care and map to a PDPM clinical category.
  • Return to provider: This indicates that the SNF will not receive payment. In such cases, one should wait for a correction or more information from the provider.
  • Resolved in hospital: Here, the selected ICD-10-CM codes do not apply to the SNF, as the condition occurred when the resident was hospitalized.
  • Reason for skilled care: The ICD-10-CM codes provided by the provider indicate why the patient needs skilled care and map to a PDPM clinical category.

Long term care staff looking to improve their PDPM reimbursements can use a long term care software that comes with PDPM mapping tools. Some best practices they can employ to ensure successful coding with PDPM include:

1. Review Transfer Records

When a resident is admitted into a long term care facility, their medical records are transferred from the hospital to the nursing home software. Reviewing these records provides helpful information for PDPM coding and establishes the resident’s care needs via the care plan software. Relevant information that MDS nurses should review during transfer includes the resident’s allergies, diagnoses, physician orders, immunization records, and vital signs.

2. Use the CMS PDPM ICD-10 CM Mapping Tool

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. MDS Nurses should use this tool to ensure transferred residents do not receive a “return to provider” ICD-10 Code.

3. Review the NTS and Speech Co-Morbidities

The PDPM Non-Therapy Ancillary (NTA) and Speech Co-Morbidities lists are helpful resources that can be used to code correctly. These lists crosswalk ICD-10-CM codes to PDPM NTA and SLP clinical categories respectively. Both can be found in the CMS PDPM ICD-10 CM Mapping tool.

4. Review the Active Diagnoses

Reviewing the Active Diagnoses is a crucial step in PDPM coding. This is because the PDPM reimbursement is based on the PDPM clinical category mapping to which a patient’s ICD-10-CM code maps.

As previously stated, the PDPM clinical categories are PT, OT, SLP, NTA, and nursing. A resident’s diagnosis can only map to one PDPM clinical category. To correctly code PDPM, MDS nurses should review the Active Diagnoses and ensure that the ICD-10-CM codes map to the correct PDPM clinical category.

5. Verify That the UB-04, MDS, and ICD-10 Codes Match

The UB-04 medical bill is the standard form used by long term care providers to bill inpatient or outpatient medical and mental health claims. It is a claim form with red ink on standard white paper. It was designed by the CMS but is now accepted and used by most healthcare insurers as well. Nurses must always verify that the UB-04, the MDS, and the ICD-10 codes all match. If they don’t, the SNF will not be eligible for PDPM reimbursement.

Contact us here if you would like to test drive our user-friendly long term care software.

Experience Care’s PDPM Diagnosis Mapping Tool

MDS nurse using the PDPM Maximizer
Experience Care’s PDPM Maximizer is a PDPM clinical category mapping tool that helps MDS nurses locate the relevant PDPM clinical categories.

In an effort to maximize reimbursements, Experience Care has worked with long term care experts to create a PDPM diagnosis mapping tool. This PDPM Maximizer is a PDPM clinical category mapping tool that helps MDS nurses locate the relevant PDPM clinical categories for transferred residents.

Using this part of our long term care software, facilities can expect their resident diagnoses and mapping—which would typically take two to three hours—to take less than 30 minutes per patient. Additionally, this PDPM mapping tool will integrate seamlessly with Experience Care’s EHR so that doctors can easily review and approve suggested MDS diagnoses.

Meanwhile, for more nurses still on paper looking for a PDPM cheat sheet, this helpful blog provides essential information on achieving a high PDPM functional score.

Importance of PDPM Clinical Category Mapping

When it comes to PDPM coding, long term care staff should take the time to review and understand the PDPM clinical category mapping process. This will ensure that the correct code is assigned for each resident, maximizing their facility’s reimbursement.

To help with the process, Experience care has created the PDPM Maximizer, a PDPM clinical category mapping tool that can save facilities time while improving accuracy. This helpful tool is essential for nursing homes and other facilities that want to maximize PDPM reimbursements based on the PDPM clinical category mapping and a patient’s ICD-10-CM code.

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Elijah Oling Wanga