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Updated: Apr 25, 2019

With CMS inking PDPM as the finalized new payment model for Medicare Part A, many SNF leaders are wondering what it means for revenue. Although CMS has stated that PDPM will be “budget neutral”, SNF revenue and margins could be significantly impacted, positively or negatively based on the skill set of staff and efficiency of intake procedures. Knowing how to assess current procedures and identify needed education will assure a smooth transition and help protect revenue streams...

Key drivers for accurate reimbursement under PDPM

  • Since PDPM bases reimbursement on clinical characteristics of a patient rather than the volume of services delivered, accurate ICD-10 coding of MDS section I0020B will be critical to achieving proper reimbursement for the services and care delivered specific to each resident’s unique needs.

  • Case mix classifications will be identified for PT, OT, ST, Nursing and Non-Therapy Ancillary. 

  • This index for PT and OT is formulated using the primary reason for SNF care and functional ability score obtained from MDS Section GG.  The Nursing case mix also includes a functional score component. Therefore, scoring a resident’s function accurately in MDS Section GG will significantly impact reimbursement.

  • For ST, the classification is derived from the presence of acute neurologic conditions, presence of swallowing disorder and/or mechanically altered diet, presence of SLP-related comorbidities and the identification of a cognitive impairment. Accurately diagnosing the cognitive component and correctly recording these determinants will be crucial for accurate reimbursement.

  • A patient will be classified under NTA by identifying comorbidities, conditions and extensive services that are highly predictive of costs and results in a weighted-count methodology. Obtaining the proper documentation to identify these factors will be a key driver for successful coding and reimbursement. 

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