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Your PDPM Questions Answered – Part 2: Therapy Case Mix Groups

In Part 2: Therapy Case Mix Groups, of our PDPM series with Relias’ Senior Analyst for SNF Regulations and Clinical Reimbursements, Ron Orth, RN, CHC, CMAC, we received so many thoughtful questions. So, Ron has taken the time over the past week to respond to the most frequently asked questions about PDPM.

Your Questions on PDPM’s Therapy Case Mix Groups

Q: If a patient is Med A and discharges on 10/1, what type MDS do we do? A0310F=10 and end of PPS? (To be covered in Part 5).

A: Yes, the change from RUG-IV to PDPM is not changing the requirements related to discharge assessments. If the resident is discharged on 10/1, then you would need to complete both an OBRA discharge assessment (A0310F) and a SNF Part A PPS Discharge (A310H). The may of course be combined.


Q: Another in-service I attended said that if more than one function score was a decimal, then to not round them individually, but wait to round the total at the bottom. Is this your understanding?

A: Yes, that is correct. Determine the score for each individual item in Section GG first (including calculation of the avg.).  Rounding of the Functional Score, if needed, would only occur when the TOTAL score is summed.  You do not round each individual score.  In the example given in the webinar, the Total score was 14.5, so this was rounded to 15.


Q: Are we able to use Z codes as a primary?

A: When assigning ICD-10-CM codes it is important to follow the Official Coding Guidelines for Coding and Reporting. The Guidelines state the following related to the use of “Z” codes

Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as first-listed or principal diagnosis.


Q: Wouldn’t that Z code (Z47.1) require and additional code to identify the joint that was replaced?

A: You are referring to the example provided about using Z47.1 as the diagnosis entered in I0020B to indicate the primary reason for the SNF admission. Since I002B only allows the reporting of 1 code, this is the only code you would use, if applicable.  However, assigning and reporting codes in the clinical record and on the Medicare claim you would need to use an additional code (e.g., Z96.641 right artificial hip joint), as instructed in the ICD-10-CM manual, to indicate the joint replaced.


Q: Where can I find the SLP comorbidity Mapping tool?  CMS PDPM page only has grouper, ICD-10, and NTA tools?

A: On the CMS PDPM website there is a link to the PDPM ICD-10 Mappings. This excel workbook contains several different worksheets (see tabs):

  1. Overview
  2. Clinical Categories by Diagnosis
  3. SLP Comorbidity
  4. NTA Comorbidity


Q: I am a Medicaid and private pay only facility, if they remove all RUG scores then how will Medicaid only be paid out?

A:  While Medicare is changing to the PDPM system, the MDS will still support and generate a RUG, as it does now, to be used for other payers that may continue with a RUGs based payment system (Medicare, Medicare Advantage, private insurance, etc.).


For additional information, check out the top questions asked for our entire PDPM webinar series.

As the focus shifts from therapy resource utilization to one of clinical characteristics and conditions, it will be important for SNF providers to receive accurate and up-to-date information related to this system. Our six part PDPM webinar series is designed with your concerns in mind. You can view the entire PDPM Webinar Series on demand today.


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