PDPM Code Lookup

Under PDPM, a resident’s clinical category — which directly drives Medicare Part A reimbursement — is determined by their primary diagnosis code recorded in MDS Item I8000. Getting it right matters, and looking it up shouldn’t require a spreadsheet.

The PDPM Code Lookup lets you search over 65,000 ICD-10-CM diagnosis codes and nearly 50,000 ICD-10-PCS procedure codes to instantly identify the correct PDPM clinical category for any resident. Search by code or keyword, filter by category, and follow the built-in step-by-step guidance to determine whether a prior inpatient surgical procedure — orthopedic or non-orthopedic — changes the default classification.

Sourced directly from the CMS ICD-10-CM/PCS Code to PDPM Clinical Category Mapping and covering all 11 clinical categories, this is the reference tool MDS coordinators and SNF billing staff can rely on when it counts.

PDPM Code Lookup

ICD-10-CM/PCS Code lookup for Medicare Part A SNF stays

📋 How to Determine a Resident’s Clinical Category

Locate the ICD-10-CM code corresponding to the primary reason for SNF care using the Diagnosis Code (CM) tab below.
Note the Default Clinical Category shown in the results (column: Default Category).
If the resident did not receive a surgical procedure during the prior inpatient stay that relates to the SNF care plan, the clinical category is the default clinical category.
If the resident did receive a surgical procedure, check the Surgery Eligible column to see if a different category may apply.
If the result shows “May be Eligible for the Non-Orthopedic Surgery Category”: search the resident’s ICD-10-PCS procedure code in the Non-Ortho Surgery tab. If found, the category is Non-Orthopedic Surgery.
If the result shows “May be Eligible for One of the Two Orthopedic Surgery Categories”: search the resident’s ICD-10-PCS procedure code in the Ortho Surgery tab. If found, use column C of that result to determine the category.
If no qualifying procedure is found, the clinical category is the default clinical category from step 2.

PDPM Clinical Categories:

Acute Infection Acute Neurologic Cancer Cardiovascular and Coagulations Medical Management Major Joint Replacement or Spinal Surgery Non-Orthopedic Surgery Non-Surgical Orthopedic/Musculoskeletal Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Pulmonary Return to Provider

When to use this tab: If the CM diagnosis code lookup shows “May be Eligible for the Non-Orthopedic Surgery Category”, search the resident’s inpatient ICD-10-PCS procedure code here. If found, the clinical category is Non-Orthopedic Surgery.

When to use this tab: If the CM diagnosis code lookup shows “May be Eligible for One of the Two Orthopedic Surgery Categories”, search the resident’s inpatient ICD-10-PCS procedure code here. The result column shows whether the category is Major Joint Replacement or Spinal Surgery or Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery).