Copyright 2019 American Health Care Association. All Rights Reserved. AHCA PDPM Resident Classification Workbook – Version 3: Example Resident Name: BETTY W Other Documents Needed for this Module Today: • AHCA PDPM MDS Form Mock-Up: Resident Example • AHCA PDPM Variable Per-Diem Rate Reference Tables Resource Other documents needed for this module when you simulate PDPM classification with your own residents: • AHCA PDPM Resident Classification Workbook: Template • AHCA PDPM MDS Form Mock-Up: Template • CMS ICD-10 Clinical Category Crosswalk (Excel file also on CMS and ahcancalED PDPM websites) • CMS ICD-10 NTA Comorbidity Crosswalk (Excel file also on CMS and ahcancalED PDPM websites) Primary Diagnosis Clinical Category Module (Steps 1-3) Step 1 – Identify ICD-10-CM Code on MDS that represents the Primary Reason for the SNF Stay MDS Field/Value Action Primary Reason for the SNF Stay ICD-10-CM Code (enter code value) I0020 = 01-13 Go to MDS Field I0020B and enter the ICD-10-CM code value into the column to the right Z47.1 AHCA PDPM Academy Workshop Pre-Requisite Webinar Modules at ahcancalED Provide an Overview of PDPM - and Guidance on How-To-Use the CMS ICD-10 Crosswalk Excel Tables Necessary for Steps 2 and 15 of this Workbook PDPM Resident Classification Workbook_Betty W - Page 1
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Copyright 2019 American Health Care Association. All Rights Reserved.
AHCA PDPM Resident Classification Workbook – Version 3: Example Resident Name: BETTY W
Other Documents Needed for this Module Today: • AHCA PDPM MDS Form Mock-Up: Resident Example• AHCA PDPM Variable Per-Diem Rate Reference Tables Resource
Other documents needed for this module when you simulate PDPM classification with your own residents: • AHCA PDPM Resident Classification Workbook: Template• AHCA PDPM MDS Form Mock-Up: Template• CMS ICD-10 Clinical Category Crosswalk (Excel file also on CMS and ahcancalED PDPM websites)• CMS ICD-10 NTA Comorbidity Crosswalk (Excel file also on CMS and ahcancalED PDPM websites)
Primary Diagnosis Clinical Category Module (Steps 1-3) Step 1 – Identify ICD-10-CM Code on MDS that represents the Primary Reason for the SNF Stay
MDS Field/Value Action Primary Reason for the SNF Stay
ICD-10-CM Code (enter code value)
I0020 = 01-13 Go to MDS Field I0020B and enter the ICD-10-CM code value into the column to the right Z47.1
AHCA PDPM Academy Workshop Pre-Requisite Webinar Modules
at ahcancalED Provide an Overview of PDPM - and
Guidance on How-To-Use the CMS ICD-10 Crosswalk Excel
Tables Necessary for Steps 2 and 15 of this Workbook
PDPM Resident Classification Workbook_Betty W - Page 1
Copyright 2019 American Health Care Association. All Rights Reserved.
Step 2 – Identify the Default Primary Diagnosis Clinical Category from the CMS “ICD-10 Clinical Category Crosswalk” Excel file tool”
cms.gov
Identify row in the CMS ICD-10 Clinical Category Crosswalk Excel file that corresponds to the Primary reason for the SNF Stay ICD-10-CMS Code identified in Step 1 (remove the decimal when examining the Excel file).
Hint: Use the “CTRL-F” function to search the CMS crosswalk file.
Download from ahcancalED: https://educate.ahcancal.org/pdpm or
Download from CMS: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html
PDPM Resident Classification Workbook_Betty W - Page 2
Copyright 2019 American Health Care Association. All Rights Reserved.
Step 3 – Identify Final Primary Diagnosis Clinical Category after considering if resident is eligible for a surgical adjustment
PDPM Resident Classification Workbook_Betty W - Page 3
Copyright 2019 American Health Care Association. All Rights Reserved.
Function Score Module (Steps 4-6)
Step 4 – Identify the PDPM Functional Score Points Applicable to Eating, Oral Hygiene, Toileting Hygiene, Bed Mobility and Transfers
Function Eating Oral Hygiene Toileting Hygiene
Bed Mobility Transfers
Sit to Lying Lying to
Sitting on Side of Bed
Sit to Stand Chair/Bed-to-Chair Transfer Toilet Transfer
MDS Field GG0130A1 GG0130B1 GG0130C1 GG0170B1 GG0170C1 GG0170D1 GG0170E1 GG0170F1
MDS Field Value
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
05, 06 4 4 4 4 4 4 4 4
04 3 3 3 3 3 3 3 3
03 2 2 2 2 2 2 2 2
02 1 1 1 1 1 1 1 1 01, 07, 09, 10, 88,
missing 0 0 0 0 0 0 0 0
Average of circled GG0170B1 and GG0170C1
Functional Score Points (round to 2 decimals)
Average of circled GG0170D1 and GG0170E1 and GG0170F1
Functional Score Points (round to 2 decimals)
4.00
PDPM Resident Classification Workbook_Betty W - Page 4
Copyright 2019 American Health Care Association. All Rights Reserved.
Step 5 – Identify the PDPM Functional Score Points Applicable to Walking
Step 6 – Identify the PDPM Functional Score Points (Rounded sum) Attributed to the PT, OT and Nursing Components
Function PT and OT Component Function Score
Nursing Component Function Score
Eating Function Score (Step 4) 4
Oral Hygiene Function Score (Step 4) 4 Toileting Hygiene Function Score (Step 4) 2 Average Bed Mobility Function Score (Step 4) 4 Average Transfer Function Score (Step 4) 2.67 Average Walking Function Score (Step 5) 2.5
PDPM Function Score (sum to 2 decimals) 19.17 PDPM Function Score (round to whole number) (range 0-24 for PT and OT, 0-16 for Nursing)
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PDPM Resident Classification Workbook_Betty W - Page 5
Copyright 2019 American Health Care Association. All Rights Reserved.
PT and OT Component Module (Step 7) Step 7 – Identify the PDPM PT and OT Component Classification & Base PDPM PT and OT Component Per-Diem Rates
PT and OT Primary Diagnosis Clinical Category (see Steps 2 or 3)
None Neither SA $15.06 $18.97 Either SB $40.31 $50.78 Both SC $58.92 $74.21
Any one Neither SD $32.34 $40.73 Either SE $51.61 $65.01 Both SF $65.79 $82.86
Any two Neither SG $45.19 $56.92 Either SH $63.13 $79.52 Both SI $77.75 $97.93
Any three Neither SJ $66.01 $83.14 Either SK $81.73 $102.95 Both SL $92.81 $116.90
PDPM Resident Classification Workbook_Betty W - Page 9
Copyright 2019 American Health Care Association. All Rights Reserved.
NTA Component Module (Steps 13-18) Step 13 – Identify the NTA Component “Points” from MDS Simple “Checklist” Items (evaluate all rows for NTA points eligibility)
Condition/Extensive Service (check all rows) MDS Field/Value NTA Points