Reimbursement under PDPM

Reimbursement under PDPM will require updates to clinical systems, policies and procedures, and operational focus.

Diagnosis coding accuracy will be paramount to appropriate payment under PDPM, as ICD-10 Diagnosis codes & other patient characteristics are used as basis for classification in determining MCR payment. The 5-day MDS will establish the PDPM payment category for the entire Medicare stay which is why it will be so important to have good processes in place for establishing the principal diagnosis and having information to support coding all active diagnosis prior to the 5-day assessment completion.

One of the key drivers of PDPM reimbursement is the clinical category the patient is assigned to based on the principal diagnosis or reason for the skilled stay. The reason for the skilled stay must be discussed immediately upon admission and there needs to be a common understanding between billing, therapy, and nursing on what the primary reason for the skilled stay is. With PDPM, this will need to be coded on the 5-day MDS and should be supported by daily documentation supporting the clinical needs and skilled services provided related to this condition.

Active diagnosis will also play a major role in setting the payment for the SLP and Non-Therapy Ancillary (NTA) PDPM components. 34 of the 50 items resulting in NTA point are related to active diagnosis coded on the 5-day MDS.

Diagnosis coding accuracy requires consistent interdisciplinary team communication, quality provider documentation, efficient systems to capture information for the five-day MDS assessment, and understanding of the ICD-10-CM coding guidelines.

You should begin preparing now for PDPM implementation by:

  1. Reviewing new admissions to see if you are currently receiving detailed enough information from providers upon admission to code all active diagnosis on the 5-day MDS. If you are not, begin establishing a plan for documentation improvement to allow an accurate representation of all active diagnosis on the 5-day MDS.
  2. Establishing a process for IDT collaboration on determining what the primary diagnosis for the skilled stay is upon admission and use the clinical category mapping tool to identify what category the diagnosis code selected will map to under PDPM.
  3. Establishing systems to audit and monitor coding accuracy. This includes your internal systems, such as triple check processes, but should also include having periodic reviews from a 3rd party to validate accuracy in coding and that your billing is supported by appropriate medical record documentation.
  4. Establishing a process for assessing staff competency in the correct assignment of diagnosis codes.
  5. Establishing a process for on-going diagnosis coding training for staff involved in assignment of diagnosis codes.

Proactive experts can meet your needs for development and ongoing implementation of your PDPM transitions plan, including ICD-10 training and auditing and monitoring of coding accuracy. Our staff includes AHIMA approved ICD-10 trainers with extensive experience in SNF operations.

Click here to learn more about Proactive’s PDPM Implementation Partnerships (pdf).

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Download Proactive’s on-demand training covering “Developing ICDd.10 Expertise for Effective Coding of Clinical Categories & Non-Therapy Ancillary” requirements. Click here for details.

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Blog by Shelly Maffia, Director of Regulatory Services, Proactive Medical Review

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