Navigating PDPM Components: An ICD-10 Mapping Guide for Skilled Nursing Facilities

Introduction: Welcome to our comprehensive training module on understanding the Patient-Driven Payment Model (PDPM) components and their mapping with ICD-10 codes in skilled nursing facilities (SNFs). Effective implementation of PDPM requires accurate diagnosis coding to ensure proper reimbursement and quality care delivery.

Overview of PDPM: The Patient-Driven Payment Model (PDPM) revolutionized Medicare reimbursement for skilled nursing facilities (SNFs) upon its implementation on October 1, 2019. Unlike the previous system, PDPM focuses on patient characteristics and clinical needs rather than therapy minutes for reimbursement.

Key Components of PDPM: Under PDPM, SNFs use six components to determine reimbursement:

1. Physical Therapy (PT)
2. Occupational Therapy (OT)
3. Speech-Language Pathology (SLP)
4. Nursing
5. Non-Therapy Ancillary (NTA)
6. Non-Case-Mix Adjusted Component

Importance of ICD-10 Coding: ICD-10 coding is essential for mapping diagnoses to PDPM components accurately. Each component's reimbursement rate is determined based on the clinical categories mapped from ICD-10 codes, emphasizing the importance of precise coding practices.

PDPM Clinical Category Mapping and ICD-10 Codes: PDPM clinical categories are mapped using ICD-10-CM codes, which describe various diagnoses and conditions. The five case-mix adjusted components (PT, OT, SLP, NTA, and Nursing) rely on specific ICD-10 codes to determine reimbursement rates. The sixth component covers unvarying resources.

Best Practices for PDPM Coding: To ensure successful coding with PDPM, SNF staff should adopt the following best practices:

1. Review Transfer Records: Utilize medical records transferred from hospitals to gather essential information for accurate PDPM coding.
2. Use the CMS PDPM ICD-10 CM Mapping Tool: Crosswalk ICD-10 codes to PDPM clinical categories using the official mapping tool provided by CMS.
3. Review NTA and Speech Co-Morbidities: Refer to NTA and SLP clinical category lists to code accurately for these components.
4. Review Active Diagnoses: Ensure ICD-10 codes match with the appropriate PDPM clinical category to optimize reimbursement.
5. Verify Code Consistency: Ensure consistency among UB-04, MDS, and ICD-10 codes to avoid reimbursement discrepancies.

Experience Care's PDPM Mapping Tool: Experience Care offers the PDPM Maximizer, a clinical category mapping tool designed to streamline PDPM diagnosis mapping and improve accuracy. This tool integrates seamlessly with Experience Care's EHR system, facilitating efficient coding and reimbursement processes.

Conclusion: Accurate ICD-10 coding and PDPM clinical category mapping are vital for maximizing reimbursement and ensuring quality care delivery in SNFs. By following best practices and utilizing tools like the PDPM Maximizer, SNFs can navigate PDPM components effectively and optimize reimbursement rates.