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On the ~Anniversary of PDPM, “Oops!” says CMS

On CMS' Technical Page, the agency announced via this post that an error was made in the PDPM Grouper! Six ICD-10 codes (T8484XA, T8389XA, T8321XA, T82399A, T82392A, and T83021A) were excluded. These codes are significant, because they contribute points toward the NTA case mix group when coded on the PPS MDS assessment.

CMS published an updated version to the PDPM Grouper DLL to correct for the mistake. Additionally, its source code and test cases are found in the zip file under the Downloads Section (labeled PDPM V1.0007 package.)

Luckily this was discovered in the final hours before closing out FY2020, and providers are encouraged to confirm the update (source code) has been installed with their software companies.

The missing codes all fall into the comorbidity description 'Complications of Specified Implanted Device or Graft.' Specific code descriptions are listed here:

  • Displacement of indwelling urethral catheter
  • Other mechanical complication of femoral arterial graft (bypass)
  • Other mechanical complication of unspecified vascular grafts
  • Breakdown (mechanical) of graft of urinary organ
  • Other specified complication of genitourinary prosthetic devices, implants and grafts
  • Pain due to internal orthopedic prosthetic devices, implants and grafts

Each of these codes contains a 7th character “A” that signifies an initial encounter. 

During the past year, these codes were the subject of many inquiries & discussions, because including an initial encounter code on a SNF claim was not within the official guidelines for coding. 

CMS was aware of the issue and clarified within the Proposed and Final Rule for 2021 responding to stakeholders' request to add ICD-10 codes containing the seventh character “D” for subsequent encounter. CMS confirmed the addition to the mappings on July 31, 2020 of the codes in the sequence above, as well as other mapping changes found here.

CMS did not remove the A sequence codes for this series of 'Complications of Specified Implanted Device or Graft' but added the D sequence. As a result: neither will flag 'Return to Provider.'

Providers are encouraged to work with physicians to document and code the most applicable diagnosis codes.

Tags: PDPM, CMS Update 2020