The transition to PDPM on October 1 brought forth a whole new reimbursement system centered around primary clinical characteristics of the patient that is dependent on five categories: PT, OT, SLP, NTA and Nursing. With the major shift from RUG-IV to PDPM, our post-acute care experts have received a multitude of questions revolving around diagnosis coding and how it greatly affects a SNF’s reimbursement under this new model. Our clinical and compliance experts, Jennifer Napier and Allen Johnson teamed up to provide tips and strategies to continually optimize accuracy under PDPM.


Choosing the right diagnosis coding is necessary when completing the MDS in order to receive the most accurate reimbursement. The patient’s primary diagnosis greatly impacts three of the five PDPM components and in cases where a medically complex patient is admitted into a SNF, there may be several primary diagnoses that can be used. The code chosen and entered in I0020B influences the payment rate for PT, OT and SLP if there is an acute neurologic condition.

The Diagnosis Code entered into I0020B will determine the Clinical Category for PT/OT and ST as a major payment component. MDS nurses will need to ensure the diagnosis entered maps to a PDPM clinical category that impacts reimbursement (and not return to provider). When you have a patient who is medically complex and there are three possible codes that could be used as the primary diagnosis (two mapping to the medical management category and one mapping to acute neurologic), choosing acute neurologic will not only result in a higher case mix group for PT and OT, but will also result in a higher case mix group for the ST component as well. There is a significant difference from using an Acute Neurologic Code over Medical Management. Concept Rehab’s PT, OT and Speech Therapy Quick Guides along with our Crosswalk Tool can help determine the impact of these different codes that can greatly affect the SNF’s financial reimbursement.