PDGM Primary Diagnosis Eligibility

What this tool answers

Under PDGM, the diagnosis you put in the primary position decides which of the twelve clinical groups a 30-day period falls into — and roughly 41% of ICD-10-CM codes are assigned to no clinical group at all. Put one of those in first and the claim comes back as a Return to Provider, unpaid, before anyone reviews the care. This checker reads the CMS grouper crosswalk directly, so for any code it gives you the clinical group CMS actually assigns, the comorbidity subgroup, and whether CMS flags the code as unacceptable or too unspecified to lead a claim.

How to read the result

Chapter

Which of the 22 ICD-10-CM chapters the code sits in. Chapters are ranges, not categories of severity — the chapter is what drives the grouping, which is why two codes that sound clinically similar can behave very differently on a claim.

PDGM clinical group

The group CMS assigns to this exact code, taken from the grouper crosswalk rather than inferred from the chapter. That distinction matters: a stroke and heart failure share ICD-10 chapter 9, but CMS puts the stroke in Neuro Rehabilitation and the heart failure in MMTA - Cardiac. "No clinical group assigned" means a period cannot be grouped from this code at all.

Comorbidity subgroup

Secondary diagnoses can raise payment through the comorbidity adjustment, but only when they fall into a recognised subgroup. This shows which subgroup the code belongs to, or that CMS assigns it none.

Return-to-provider risk

Built from the flags CMS sets on the code — unacceptable in the primary position, too unspecified, a manifestation that needs its underlying condition coded first, or an external-cause code. A high flag is a prompt to find a more specific code before you bill.

Common questions