The Patient Driven Payment Model, brought to us by Medicare starting October 1, 2019, represents one of the biggest changes in payment models for skilled nursing providers and is very much on the minds of affected organizations across the country.

Two facts about PDPM stand out and one is catching the attention of many. Reimbursement is driven by:

  • Patient characteristics
  • ICD- 10 Codes

Describing patient characteristics, while in more completeness and specificity, is not seen as daunting as determining the accurate ICD-10 Codes from the thousands available.

Good news on coding from the American Health Care Association:

While PDPM requires more accuracy and precision in ICD-10 Coding, MDS nurses do NOT need to become expert coders.

Educate your current staff. Evaluate the support from your EHR — START NOW

A Few Coding Basics:

  • The ICD- 10 for the Primary Diagnosis is the key determinant of payment.
  • Primary Diagnosis refers to the reason the patient needs a Medicare A stay.
  • This is new and the Primary Diagnosis is likely to differ from the hospital codes.
  • ICD- 10 information is also needed to assign a patient to a therapy service component.

It is not too late to educate your staff – AHCA and Leading Age have training opportunities.

Begin now to evaluate the coding and validation support from your EHR.

Our next blog post will discuss the need for evaluation, communication, and documentation to survive and flourish under PDPM.