An update to the PDPM Grouper DLL has been posted, along with its source code and test cases. This version, V1.0009, adds support for new ICD-10 codes that may be used for assessments with target date on or after January 1, 2021: Z11.52, Z20.822, Z86.16, M35.81, M35.89 and J12.82. (Note that codes M35.81 and M35.89 replace code M35.8, which should no longer be used on assessments with target date on or after January 1, 2021.)

The Mappings file contains: 

• Mapping of the ICD-10-CM Recorded in Item I0020B of the MDS Assessment to PDPM Clinical Categories 
• Mapping of Comorbidities Included in the PDPM SLP Component to ICD-10-CM Codes
• Mapping of Comorbidities Included in the PDPM NTA Component to ICD-10-CM Codes

These are the codes added in the January 2021 update:

Z11.52 — Encounter for screening for COVID-19

Z20.822 — Contact with and (suspected) exposure to COVID-19

Z86.16 — Personal history of COVID-19

M35.81 — Multisystem inflammatory syndrome (MIS)

M35.89 — Other specified systemic involvement of connective tissue

J12.82 — Pneumonia due to coronavirus disease 2019

(Note that codes M35.81 and M35.89 replace code M35.8, which should no longer be used on assessments with target date on or after January 1, 2021.)

This is the seventh release (sixth production release, since 1.0005 was a beta release).

This release also adds six ICD-10 codes that were inadvertently excluded from the NTA calculation in V1.0006:

• T8484XA

• T8389XA

• T8321XA

• T82399A

• T82392A

 • T83021A 

Key information about how to submit MDS files and how to obtain and understand error messages on initial and final validation reports. 

Skilled nursing facilities now have more than a year of experience with the Patient-Driven Payment Model (PDPM), the updated case-mix classification system used in the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) that includes five case-mix-adjusted payment components: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillaries (NTA). The NTA component uses a weighted comorbidity score (i.e., high-cost conditions or extensive services count for more points) to assign a SNF resident to an NTA case-mix group.

 

A resident’s NTA score is the sum of the points associated with each comorbidity that they have. For example, a resident with IV medications (5 points) coded in MDS item O0100H2, diabetes mellitus (2 points) coded in I2099, isolation (1 point) coded in O0100M2, and wound infection (2 points) coded in I2500 would have a total NTA comorbidity score of 10. The NTA case-mix groups are based on NTA score ranges: 0 (NF), 1 – 2 (NE), 3 – 5 (ND), 6 – 8 (NC), 9 – 11 (NB), or 12+ (NA), according to table 17, “NTA Case-Mix Groups,” in chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. Therefore, a resident with an NTA comorbidity score of 10 would qualify for the NB NTA case-mix group.

 

The bottom line is that accurate payment in the NTA component depends on coding each and every NTA comorbidity the resident qualifies for according to the coding instructions in the RAI User’s Manual. Taking the following steps can help nurse assessment coordinators (NACs) capture the optimal NTA comorbidity score:

Navigating the COVID-19 public health emergency can be difficult for skilled nursing facilities (SNFs). However, no matter what the challenges are—staffing shortages, time-consuming infection prevention and control practices, the need to rearrange schedules and duties to preserve personal protective equipment (PPE), residents who need extra time and attention, or the myriad other issues—providers still have to be paid, and that means nurse assessment coordinators (NACs) need to do internal audits so they are ready to back up Patient-Driven Payment Model (PDPM) case-mix classifications for Part A residents if a Medicare auditor comes knocking.

 

What to do going forward

“The key to efficient PDPM internal audits during a COVID-19 outbreak or any crisis is focus,” says Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH. “Obviously, the best practice is to audit every MDS item and look for missed coding opportunities, as well as double-checking what you have already coded. However, that may not always be a realistic option, especially during a pandemic when, for example, you may need to work the floor because of a staffing shortage. In addition, a full audit isn’t necessary to be sure you can defend your billing to a Medicare auditor.”

The Centers for Medicare and Medicaid Services (CMS) gave states the option to collect Patient-Driven Payment Model (PDPM) billing codes on OBRA assessments when not combined with a Medicare PPS 5-Day assessment, beginning Oct. 1, 2020. While most of the information used to establish these codes is already on the OBRA assessments, the additional data collection will require both time to complete and training to perform correctly. Notably, the addition of completing the admission performance column for section GG (Functional Abilities) will take the most time. A lack of proper training for the staff completing this section has the potential to cause inaccuracies and confusion among direct care staff. However, the stress and workload can be mitigated with a strong preparation plan and ongoing support to direct care staff. Follow these four steps to ensure your team is ready to complete successfully the documentation and data collection for section GG on OBRA assessments:

1.      Understand how your state is using the information and expected future implications

“Does this surgery count as a major surgery?” is one of the most frequently asked questions that nurse assessment coordinators (NACs) have about MDS items J2100 (Recent Surgery Requiring Active SNF Care) and J2300 – J5000 (Recent Surgeries Requiring Active SNF Care: Surgical Procedures), says Carol Maher, RN-BC, RAC-MTA, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.

 

“It’s an important question because capturing a major surgery in J2100 and J2300 – J5000 can make a difference in the Medicare Part A payment that you receive for the physical therapy (PT) and occupational therapy (OT) components under the Patient-Driven Payment Model (PDPM),” says Maher. “A major surgery can move the resident from their default primary diagnosis clinical category established in I0020B (ICD Code/Primary Medical Condition) into a potentially higher-paying surgical clinical category for PT and OT.”