The Patient-Driven Payment Model (PDPM) has been the reimbursement methodology for Medicare Part A in the Skilled Nursing Facility (SNF) since October 1, 2019, with updated regulations effective every October 1st. Each fiscal year, the Centers for Medicare & Medicaid Services (CMS) releases the updated ICD-10 CM guidance for the new fiscal year, the ICD-10-CM Official Guidelines for Coding and Reporting.
In addition to these ICD-10 coding changes or updates, SNFs must be aware of the changes in the FY 2023 PDPM ICD-10 Mapping. The PDPM ICD-10 Mapping is the list of diagnoses to classify a resident into one of the ten PDPM Clinical Categories and then classify the resident’s comorbidities based on the reported active diagnoses as part of the PDPM reimbursement system.
The main reason for the focus of care for the resident’s admission to the SNF is the principal diagnosis or the ICD-10 code reported in the Minimum Data Set (MDS), item I0020B. Using the PDPM ICD-10 Mapping, this principal diagnosis is mapped into one of ten PDPM Clinical Categories – (1) Major Joint Replacement or Spinal Surgery, (2) Non-Surgical Orthopedic/Musculoskeletal, (3) Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery), (4) Acute Infections, (5) Medical Management, (6) Cancer, (7) Pulmonary, (8) Cardiovascular and Coagulations, (9) Acute Neurologic, or (10) Non-orthopedic Surgery. The Clinical Category of the principal diagnosis is the basis of the PDPM reimbursement calculation for the Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) components. It is important to note that not all ICD-10 codes fall into a PDPM Clinical Category. Several diagnoses or ICD-10 codes under PDPM are classified as Return to Provider (RTP) codes.
RTP codes can NOT be used as the primary diagnosis because these codes are not listed under one of the ten PDPM Clinical Categories, which is part of the reimbursement calculation. Remember, active diagnoses that are RTP codes are not used as primary diagnoses but should be coded in the MDS Section I. The additional active diagnoses are part of the PDPM reimbursement calculation for the resident’s comorbidities under the SLP and Non-Therapy Ancillary (NTA) components.
The ICD-10-CM Official Guidelines for Coding and Reporting contains instructions on identifying diagnosis codes to the utmost detail and accuracy, representing the resident’s condition supported by the documentation. An example is using the ICD-10 code that represents the affected side, right, left, or both sides, instead of using the code that has an unspecified side.
According to CMS, there are ICD-10 codes that would provide a higher level of specificity; therefore, the following ICD-10 codes have been reclassified based on the FY 2023 PDPM ICD-10 Mapping.
| ICD-10-CM Code | Description | FY 2022Default Clinical Category | FY 2023Default Clinical Category |
| D75.839 | Thrombocytosis, unspecified | Cardiovascular and Coagulations | Return to Provider |
| D89.44 | Hereditary alpha tryptasemia | Medical Management | Return to Provider |
| F32.A | Depression, unspecified | Medical Management | Return to Provider |
| G92.9 | Unspecified toxic encephalopathy | Acute Neurologic | Return to Provider |
| K22.11 | Ulcer of esophagus with bleeding | Return to Provider | Medical Management |
| K25.0 | Acute gastric ulcer with hemorrhage | Return to Provider | Medical Management |
| K25.1 | Acute gastric ulcer with perforation | Return to Provider | Medical Management |
| K25.2 | Acute gastric ulcer with both hemorrhage and perforation | Return to Provider | Medical Management |
| K26.0 | Acute duodenal ulcer with hemorrhage | Return to Provider | Medical Management |
| K26.1 | Acute duodenal ulcer with perforation | Return to Provider | Medical Management |
| K26.2 | Acute duodenal ulcer with both hemorrhage and perforation | Return to Provider | Medical Management |
| K27.0 | Acute peptic ulcer, site unspecified, with hemorrhage | Return to Provider | Medical Management |
| K27.1 | Acute peptic ulcer, site unspecified, with perforation | Return to Provider | Medical Management |
| K27.2 | Acute peptic ulcer, site unspecified, with both hemorrhage and perforation | Return to Provider | Medical Management |
| K28.0 | Acute gastrojejunal ulcer with hemorrhage | Return to Provider | Medical Management |
| K28.1 | Acute gastrojejunal ulcer with perforation | Return to Provider | Medical Management |
| K28.2 | Acute gastrojejunal ulcer with both hemorrhage and perforation | Return to Provider | Medical Management |
| K29.01 | Acute gastritis with bleeding | Return to Provider | Medical Management |
| M54.50 | Low back pain, unspecified | Non-Surgical Orthopedic/Musculoskeletal | Return to Provider |
The Resident Assessment Instrument (RAI) Manual provides guidance, instructions, and examples for accurately coding the MDS. The updated RAI Manual Version 3.0, Chapter 3, Section I – Diagnoses includes clarification on the supporting documentation needed before assigning a diagnosis such as a mental disorder.
According to the example in the RAI Manual:
The resident was admitted without a diagnosis of schizophrenia. After admission, the resident is prescribed an antipsychotic medication for schizophrenia by the primary care physician. However, the resident’s medical record includes no documentation of a detailed evaluation by an appropriate practitioner of the resident’s mental, physical, psychosocial, and functional status (§483.45(e)) and persistent behaviors for six months prior to the start of the antipsychotic medication in accordance with professional standards. (CMS, 2022, p.2)
Coding: Schizophrenia, MDS item I6000 would not be checked.
Rationale: Although the resident has a physician diagnosis of schizophrenia and is receiving antipsychotic medications, coding the schizophrenia diagnosis would not be appropriate because of the lack of documentation of a detailed evaluation, in accordance with professional standards (§483.21(b)(3)(i)), of the resident’s mental, physical, psychosocial, and functional status (§483.45(e)) and persistent behaviors for the time period required.
Guidance was added related to potentially misdiagnosed residents. The RAI Manual Chapter 3, Section I – Diagnoses states,
In situations where practitioners have potentially misdiagnosed residents with a condition for which there is a lack of appropriate diagnostic information in the medical record, such as for a mental disorder, the corresponding diagnosis in Section I should not be coded, and a referral by the facility and/or the survey team to the State Medical Boards or Boards of Nursing may be necessary. (CMS, 2022, p.2)
A best practice is to check the CMS website for SNF updates routinely.
LW Consulting, Inc. offers a comprehensive range of services that can help your organization’s compliance with MDS coding and reporting, including:
- Reviewing pre-bill MDS audits to identify coding variances that can be corrected prior to the MDS completion, for both long-term care and short stay MDSs.
- Conducting PDPM accuracy audits to identify opportunities for systems changes, training and education, and IDT communication.
- Performing annual MDS audits as part of the Compliance Program’s external review requirements.
- Reviewing policies and procedures, meeting format, education needs, and system assessments.
- Developing response to appeals and denials, trend analysis, and risk assessments.
