AHCA: CMS Releases Updated PDPM Guidance Materials

Lisa Volk and Nancy Leveille in Clinical & Quality

On April 4, the Centers for Medicare & Medicaid Services (CMS) released an array of updated Patient-Driven Payment Model (PDPM) materials. First, CMS updated its frequently asked questions (FAQs) related to PDPM policy and implementation. 

  • PDPM FAQs (click here):  The FAQ documents constitute sub-regulatory guidance for the new payment system. In this document, CMS provides updates and additions to CMS policy.

Second, CMS released additional updated resources relevant to PDPM implementation, including various coding crosswalks and classification logic.

  • PDPM Classification Walkthrough (click here) – In this document, CMS lays out how patients are classified in the PDPM components (e.g., Physical Therapy, Occupational Therapy, Speech Language Pathology, Nursing, and Non-Therapy Ancillaries) Case Mix Groups (CMGs) and related Case Mix Indices.
  • PDPM GROUPER Logic (SAS) (click here) – The GROUPER logic materials provide technical programming guidance for software which classifies patients into component CMGs.

  • PDPM ICD-10 Mappings (click here) – For PDPM, CMS mapped an array of ICD-10 codes to clinical categories. In this excel file, CMS has updated the ICD-10 diagnosis codes (ICD-10-CM) codes which map to the clinical categories. 

Next Steps

AHCA will produce a summary of what changed in the March 4 versions compared to prior reversions of the CMS guidance materials in the coming days. If you have questions, suggestions or concerns, please contact us at pdpm@ahca.org 


Lisa Volk, RN, B.P.S., LNHA
Director, Clinical & Quality Services
518-462-4800 x15

Nancy Leveille, RN, MS
Executive Director
518-462-4800 x20