PDPM Billing Optimization & Compliance for SNFs

PDPM Billing Optimization & Compliance for SNFs

The Patient-Driven Payment Model replaced RUG-IV in October 2019, fundamentally changing how Medicare pays for skilled nursing facility care. Under PDPM, reimbursement is no longer driven by therapy minutes — it is driven by clinical complexity across five case-mix adjusted components: Physical Therapy, Occupational Therapy, Speech-Language Pathology, Nursing, and Non-Therapy Ancillary services.

This is a significant structural change with significant financial implications. Facilities that understood the new model quickly — and built clinical documentation and MDS coding practices to support accurate PDPM classification — captured the reimbursement their patients' acuity justified. Facilities that did not adapt are systematically under-billing for the care they are providing.

At the same time, CMS and its contractors are increasingly focused on PDPM compliance. Inappropriate upcoding, unsupported clinical categorization, and inflated NTA scoring are areas of active RAC and TPE audit interest. The goal of PDPM optimization is not to maximize reimbursement regardless of what the documentation supports — it is to ensure that your documentation accurately reflects your patients' clinical complexity, and that your billing reflects what your documentation actually supports.

PDPM Optimization Areas

Clinical Categorization (Section I)

• Evaluation of primary diagnosis selection and assignment to the appropriate PDPM clinical category

• Identification of alternative eligible diagnoses supported by clinical documentation

• Training for MDS teams on accurate, defensible clinical categorization practices

• Alignment with Centers for Medicare & Medicaid Services expectations for documentation and coding integrity

NTA Score Optimization

• Comprehensive audit of Non-Therapy Ancillary (NTA) scoring elements

• Crosswalk comparison between clinical records, physician orders, MAR/TAR, and MDS coding

• Identification of missed, clinically supported NTA points

• Development of documentation workflows to ensure consistent and compliant capture

SLP Comorbidity Capture

• Identification of qualifying comorbidities impacting the Speech-Language Pathology (SLP) component

• Review of medical history versus current documentation visibility for MDS capture

• Standardization of documentation practices to ensure consistent recognition of SLP comorbidities

• Education for interdisciplinary teams on proper documentation linkage

Section GG Functional Assessment Accuracy

• Validation of GG functional scores against therapy and nursing documentation

• Identification of under-coding and over-coding risks impacting reimbursement and compliance

• Training on accurate GG coding during the assessment reference period

• Alignment of interdisciplinary documentation to support coded functional status

Therapy Utilization Under PDPM

• Analysis of therapy utilization patterns relative to resident acuity and clinical need

• Review of therapy delivery in relation to CMS expectations and audit risk exposure

• Assessment of documentation supporting therapy services and medical necessity

• Recommendations balancing quality outcomes, compliance, and operational efficiency

What We Deliver

• PDPM Revenue Analysis — Quantified assessment of current reimbursement accuracy, including estimated financial impact of identified coding gaps and missed opportunities

• MDS Coding Recommendations — Resident-specific, defensible coding corrections supported by clinical documentation and aligned with Centers for Medicare & Medicaid Services guidelines

• Staff Training — Targeted education for MDS coordinators, nursing, and therapy teams on PDPM components, coding accuracy, and documentation requirements

• Ongoing Monitoring Protocol — Structured monthly PDPM accuracy review process to ensure sustained compliance and reimbursement integrity