Return to Provider Codes and the Patient Driven Payment Model

ICD-10 Codes and PDPM Mapping

The Centers for Medicare and Medicaid Services (CMS) have identified, categorized, and mapped medical conditions through ICD-10 coding which predict payment for physical therapy, occupational therapy, speech therapy, nursing, and non-therapy ancillary needs.

Physical therapy, occupational therapy, and speech therapy will be categorized based on the primary diagnosis for the SNF stay as coded in item I0020B. This single primary diagnosis will then map to 1 of 10 PDPM clinical categories which directly impacts reimbursement.

Are “return to provider” codes allowed?

Certain codes entered in I0020B (primary reason for skilled stay) will map to “return to provider”. If a “return to provider” code is used in I0020B of the MDS, the claim will be returned for revision of the code entered in I0020B.

The “return to provider” codes include symptom codes that may be used by physical, occupational, and speech therapists as treatment diagnoses on their plans of care.

Examples include but are not limited to: M25.561 pain in right knee, M62.81 muscle weakness (generalized), R13.11 dysphagia – oral phase, R27.9 unspecified lack of coordination, R26.81 unsteadiness on feet, and R41.841 cognitive communication deficit.

Symptom codes do not represent the primary reason for the SNF stay; therefore, they are not appropriate for I0020B. However, they do support the highly specified and individualized treatment provided to the patient by therapy and must be coded by therapy as treatment diagnoses and reflected on the UB04 and other areas of the MDS. This coding ensures a full clinical picture of the patient’s clinical characteristics is provided and ensures the claim is supported in the event additional review is requested.

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