ICD-10-CM AND THE PDPM

[Pages:79]ICD-10-CM AND

THE PDPM

Mary Ann P. Leonard, RHIA, RAC-CT Health Information Professionals malhip@

ICD-10-CM AND THE PDPM

OBJECTIVES To understand how the ICD-10-CM codes are utilized by the

new payment system To understand how the Clinical Category Mapping is utilized To understand in which `buckets' of the PDPM the diagnostic

code is being used To provide recommendations related to the best utilization

of the ICD-10-CM codes

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ICD-10-CM AND THE PDPM

ICD-10-CM SOURCE

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ICD-10-CM AND THE PDPM

Where does the International Classification of Disease, Clinical Modification (ICD-10-CM) come from? Developed through the World Health Organization Adopted by countries around the globe Adapted for the needs of the specific country Utilized to gather information/statistics on diseases Beta testing for ICD-11-CM has been completed

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ICD-10-CM AND THE PDPM

Sources for criteria for assigning the ICD-10-CM codes

Coding Guidelines published by CDC, DHHS/CMS

Coding Clinic published by the American Hospital Association

? Managed by the Cooperating Parties ? American Hospital Association, American Health Information Association, National Center for Health Statistics, Centers for Medicare/Medicaid Services

? Question and answer format, questions/situations submitted by multiple sources

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ICD-10-CM AND THE PDPM

What was the impact of ICD-10-CM in the past?

ICD-10-CM codes were not utilized under RUGs as a direct impact on reimbursement

Diagnoses which impacted RUGs were primarily check-offs in section I, e.g. hemiplegia, Diabetes Mellitus or incorporated in other section of the MDS e.g. Section O for trach/vent care

Under PDPM there is a direct relationship between the code assignment and payment categories

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ICD-10-CM AND THE PDPM

Factors which impact ICD-10-CM code assignment Information provided from acute care ? ranges from nothing

to volumes of paper/information (some provide EHR portals) Can only use diagnoses documented by a provider

(physician, nurse practitioner or physician assistant) Lack of specificity from the provider e.g. hip fracture,

pneumonia, stroke, DM, HTN, etc. Lack of clarity re: the principal or primary diagnosis Culture of therapy seen as the driving force for skilled care

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POLICY AND PROCEDURE

Every facility should have a policy/procedure on diagnostic code assignment

Some items to be addressed are, but not limited to, ?Following the Coding Guidelines ?What diagnoses are to be used ?Timeframe for coding ?Documentation sources for the diagnoses ?Querying of the Provider

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