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ICD-10 expertise: Critical for new PDPM reimbursement model

September 10, 2018 Article 2 min read
Denise Leonard
Does your organization have the ICD-10 coding expertise necessary to be successful under CMS’s new PDPM reimbursement model? Learn why ICD-10 expertise is critical to thrive under the new model.
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The new reimbursement model, also known as Patient-Driven Payment Model (PDPM), comes with big changes that skilled nursing facilities (SNFs) need to be aware of. Although the rule isn’t effective until October 2019, providers should begin to assess both impact and resources now.

The model is now less focused on the number of therapy minutes spent with residents and more focused on residents’ clinical characteristics. Under PDPM, initial assessments will no longer focus on rehab versus non-rehab. Instead, providers will be required to classify the resident into a clinical category that represents the clinical reasons for the resident’s SNF stay.

As the final rule notes, “Moving to a system that utilizes the primary patient diagnosis as the key determinant of payment will help to ensure that the patients’ unique condition and goals is the primary driver of care planning and care delivery and case mix classification, rather than the patients’ ability to tolerate a high volume of therapy services.” The final rule also provides table 14, reprinted below, which outlines 10 clinical categories under PDPM:

Additionally, CMS has made available a PDPM Clinical Category Mapping tool, which helps providers match the ICD-10-PCS code to the clinical categories outlined above. However, it’ll be up to the provider to have a thorough understanding of the ICD-10 system to capture the ICD-10 code that supports the residents’ qualifying stay as well as the ICD-10 codes that capture the residents’ comorbidities and requirements for extensive services.

CMS has put ownership on providers by stating in the final rule, “It is the responsibility of the provider to ensure their staff is properly trained to perform these types of more general tasks that are not specific to a given payer or requirement.” For this reason, a thorough understanding of the ICD-10 system will be critical to thrive under the new reimbursement model.

Since most SNFs don’t have a certified coder on staff, how can providers gain a deeper understanding of the ICD-10 system?

Assess how your facility will meet PDPM requirements now

Providers should begin now to assess how PDPM will affect their organization and what their needs will be to reduce the impact of the transition. The solution will vary for each provider and facility.

Providers should start to identify and perhaps incentivize an individual in each facility to attain a professional coding designation available through the American Academy of Professional Coders (AAPC). No requirement for preferred credentialing has been highlighted by CMS, but the most applicable credential would be Certified Inpatient Coder (CIC). This designation validates an individual’s knowledge and expertise abstracting information from the medical record for ICD-10-CM and ICD-10-PCS coding, which are the ICD-10 codes specifically referenced in the final rule.

The CIC designation also indicates having knowledge of the ICD-10 codes used by the hospital in conjunction with the qualifying inpatient stay. Keep in mind, obtaining a CIC designation requires six to nine months’ lead-time for completing online or self-study courses and the certification exam.

Providers should begin now to assess how PDPM will affect their organization and what their needs will be to reduce the impact of the transition.  

Implementation will be here before you know it

Planning ahead will ensure your organization doesn’t take a financial hit starting October 2019. Learn the ins and outs of PDPM reimbursement, and identify how your organization will gain the necessary ICD-10 skills and expertise to thrive under the new model.

Have questions? Our healthcare consulting team can help you prepare for and navigate the upcoming changes. Contact us today.

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