WHY IS ICD-10 CODING SO CRITICAL UNDER PDPM?

Updated: Apr 26, 2019


Several crucial payment components of PDPM will utilize the patient’s ICD-10 diagnosis (which is entered in the first line of MDS section 10020B) to categorize a patient into one of ten clinical categories. The diagnosis code entered is instructed to be the diagnosis that represents the primary reason for the resident’s Part A SNF stay and will essentially set the rate of payment for the entire stay. 


Not only will a provider need to choose the most relevant ICD-10 diagnosis code, but they will also need to ensure it maps to one of the diagnoses in the CMS “SNF PDPM Clinical Category Mapping” to ensure the resident is categorized into the most accurate clinical category.  

Click here for the clinical category mapping.

This is a significant change in practice because:The diagnosis code used as the “primary skilled diagnosis” has never impacted payment before. The current directions in the MDS 3.0 RAI Manual for entering diagnoses in I8000 indicate to only include an “additional active diagnosis” in I8000, if the disease or condition is not already indicated in I0100-I6500.   With the implementation of PDPM looming around the corner, facilities are forced to look at current practices as they relate to diagnosis coding. Facilities have just under a year to review practices and tighten up processes to facilitate a seamless transition to PDPM and should address the following:Who is currently responsible for ICD-10 coding and what kind of qualifications/training do they have?What process will you implement so that even during evening and weekend admissions the correct ICD-10 code is determined and is communicated to all members of the interdisciplinary team so that patients can be categorized into the appropriate clinical pathway?

Jennifer Napier, RN, RAC-CT, QCP Compliance Manager, Concept Rehab   ​

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