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     PDPM Payment Component: PT      

STEP #1

Determine the resident’s primary diagnosis clinical category using the ICD-10-CM code recorded in MDS item I0020B. To do so, refer to the PDPM Clinical Categories to ICD-10 Diagnosis Codes mapping (available at www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/SNFPPS/PDPM.html), which maps a resident’s primary diagnosis as recorded in MDS item I0020B to the 10 PDPM primary diagnosis clinical categories.

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 resident’s prior inpatient procedure history. For these codes, a resident may be categorized into a surgical clinical category if the resident received a surgical procedure during the prior inpatient stay that relates to the primary reason for the Part A SNF stay as indicated by item J2100. If the PDPM clinical category mapping indicates that the resident’s primary diagnosis code is eligible for one of the two orthopedic surgery categories (major joint replacement or spinal surgery, and orthopedic surgery (except major joint replacement or spinal surgery)), then proceed to Step 1A; if eligible for the non-orthopedic surgery category, then proceed to Step 1C. Otherwise, proceed to Step 1D to finalize the primary diagnosis clinical category assignment.

STEP #1A

Determine whether the resident received a major joint replacement or spinal surgery during the prior inpatient stay using item J2100. If any of the procedures indicated in items J2300, J2310, J2320, J2330, J2400, J2410, or J2420 was performed during the prior inpatient stay, then the resident is categorized into the major joint replacement or spinal surgery clinical category. If none of these procedures was performed, the resident did not receive major joint replacement or spinal surgery during the prior inpatient stay for purposes of determining the PDPM classification.

Resident Eligible for Surgical Clinical Category and Received Major Joint Replacement or

Spinal Surgery? (Yes/No)          

If the resident received Major Joint Replacement or Spinal Surgery, then the primary diagnosis clinical category is Major Joint Replacement or Spinal Surgery. Proceed to Step 1D to finalize the primary diagnosis clinical category assignment. Otherwise, proceed to Step 1B.