Harmony Healthcare International (HHI) Blog

PDPM - Where are We Now Q&A: Part 8

C.A.R.E.S.

Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency Survey


Kris Big Crowd Carolina Question 8 of 9: Can you talk a little bit about the use of Return-to-Provider codes ?

When coding the MDS in Section I0020B, we need to identify the primary medical diagnosis.  This represents the reason a person skilled and allows them to access their skilled Medicare A benefit.  These medical diagnosis codes are utilized with the CMS crosswalk to determine the PDPM clinical category.

Occasionally symptom or treatment codes are placed in Section I0020B.  When this occurs, the claims will Return to Provider for correction.

Return to Provider codes are often the treatment diagnoses used by therapists.  These treatment diagnoses, often symptoms, help to support the reason/need for the skilled benefit and justify the individual POC and rehab services.

Return to Provider codes, alone, are not specific enough to be considered a Medical or Primary Diagnosis.  They do, however, help to create a picture or story of the patient’s condition and care needed to reach their PLOF.

Examples of such treatment codes may include:  Dysphagia R13.11; Muscle Weakness M62.81; Other Abnormalities of Gait and Mobility R26.89.

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Topics: Coding, PDPM

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