16 Apr 2019

Worried about PDPM & ICD-10 Diagnoses?

Rod Baird

PDPM: Don't Panic!

There's already a solution at hand – your buildings' Medical Staff.


Otherwise healthy people do drown in shallow water – simply because they are too panicked to stand up. We’re writing this in early spring 2019, and many SNF buildings are panicked about the impending change to PDPM- the CMS Patient Driven Payment Model. Starting Oct. 1st 2019, Medicare payments for Skilled Nursing become linked to a patient’s medical and functional problems, not the minutes of therapy they’re going to receive. Those problems are captured from ICD-10 Diagnosis codes, and standardized assessments.

Every SNF already has a trove of ICD-10 data for their Residents!

Don't panic – help is as close as your own SNF Medical Record! Your Medical Staff already uses ICD-10 codes on every encounter (i.e. a visit) they have with your residents. A physician, NP, or PA can’t receive any 3rd party insurance payment without submitting a claim which includes one or more ICD-10 Codes.

Federal regulations require Nursing Facilities include copies of Practitioner Notes (encounters) in the official Medical Record. The majority of PALTC medical practices already use their own EHRs. Encounter notes from any modern Physicians' EHR always include a problem list (diagnoses).

More than 25% of all SNF/NF Practitioner encounters are already documented in the GEHRIMED™ EHR software, provided by our company. What's also certain – the Medical Practices using GEHRIMED™ can freely share their ICD-10 problem lists with the SNF/NF buildings they serve.

Major shortcomings for PDPM possible in Physicians’ ICD-10 problem list

What we are also certain of – very few of the PALTC Medical Groups are selecting ICD-10s with PDPM coding in mind. The medical staff serving Nursing Facilities are paid by Medicare Part B – not Part A. For Part B payments, the encounter is ‘coded’ around the Patient’s primary medical problem the Practitioner treated. The encounter note(s) may include ICD-10 codes that are important for PDPM rate determination, but that is fortuitous – not planned.

PDPM is a great opportunity to create a Patient-Centered CareTeam

There are 6 months remaining until PDPM is a reality – use them wisely. It’s time for SNF leaders to sit down with the Medical Groups covering their facilities and start forging a collaboration. While the Patient's care should be the reason for collaboration – the reality of aligning around the ICD-10 Problem list is great tactical project. Technology is an indispensable tool in helping coordinate patient care across organizations; GPM has an evolving suite of software solutions that foster collaborative care of LTPAC residents. They include:

  • GEHRIMED™ the electronic health record for LTPAC Medical Groups.
  • CareTeam an open and secure interoperability platform which links medical groups, facilities, and others in a shared care model.
  • CareNote allows anyone enrolled in CareTeam to securely share patient information and have those messages archived in the individual's physician medical record.
  • Patient Pattern Insights a 3rd party analytics tool linked to and CareTeam.

Why Patient Pattern?

In the opening paragraph of this post, we stated ‘those problems are captured from ICD-10 Diagnosis codes, and standardized assessments. That statement is true but misleading! The term standardized assessment refers to the MDS 3.0 – the set of standard patient assessment forms used for all SNF & NF residents. The form is standardized, but the assessment itself is not a standardized assessment tool. In its native form, the MDS doesn’t forecast anything about the resident’s need. However, it is the only standard that’s available across all SNF-NFs in the USA. Is it possible to use data from the MDS, and other assessments to create a true ‘standardized assessment’?

We believe the answer is a resounding YES – there is enough data to calculate something that’s actually important – an individual Frailty Score. What’s Frailty? Think about the population that we consider LTPAC – they have multiple medical diagnoses, but those illnesses are far less than the sum of their problems. What transforms an otherwise functional community resident into an individual needing institutional services is their inability to maintain independence. There are multiple reasons that might cause that loss, some temporary, others permanent. Many factors can contribute – loss of physical abilities, cognitive loss, drug side effects, disease processes, etc. A major operation can cause a temporary spike in ‘frailty’, while delirium acquired during the hospitalization might lead to a permanent increase in ‘frailty.

There are many ways to estimate ‘frailty’. Patient Pattern is designed to incorporate all of the available ‘measures’ and combine them into a single value that can guide the care team and family in predicting likely outcomes.

We’re incorporating this into our business model because Frailty is easy for members of the care team to understand. If you work with LTPAC residents, you’ll learn to recognize ‘frailty’ intuitively, Patient Pattern enables you to express that in a standards based manner.

Want more information? Watch our PDPM webinar.