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Mastering PDPM: How SNFs Can Optimize Coding and Claims
The Patient-Driven Payment Model (PDPM) has changed how Skilled Nursing Facilities (SNFs) get reimbursed. Unlike the old RUG-IV system, PDPM pays based on a resident’s
clinical needs, not therapy minutes. Missing or incomplete documentation can lead to lost revenue, claim denials, or costly audits.
With FY 2026 updates, SNFs need to stay on top of changes:
34 ICD-10 code updates effective October 1, 2025
Payment rates adjusted by 3.2% plus market basket updates
Removal of some Social Determinants of Health from MD
Health Equity Adjustment removed from SNF Value-Based Purchasing
Outsourcing SNF billing and coding services can help facilities stay accurate, compliant, and efficient.
1. Focus on Admission & 5-Day MDS
Structured Admission Workflow: Nurses, therapists, and MDS staff should collaborate from day one.
Section GG Accuracy: Document residents’ abilities to perform daily tasks carefully.
Interim Payment Assessments (IPAs): Complete them promptly if care needs change.
Accurate documentation ensures correct PDPM payments and reduces denials.
2. Use ICD-10 Codes Effectively
Choose specific primary diagnosis codes, not general ones.
Identify all comorbidities like diabetes, heart disease, or stroke.
Maintain a high-impact ICD-10 code list and train staff to use it.
Correct ICD-10 coding directly impacts nursing, therapy, and non-therapy reimbursement under PDPM.
3. Maximize Non-Therapy Ancillary (NTA) Points
Screen residents early for IV meds, complex wound care, or isolation.
Monitor clinical changes daily and update the MDS.
Document every NTA condition clearly in medical records.
Proper NTA documentation increases reimbursement and ensures compliance.
4. Optimize Speech-Language Pathology (SLP)
Screen residents for speech or swallowing issues within 48 hours.
Ensure SLP documentation aligns with ICD-10 codes.
Conduct collaborative case reviews with nurses and MDS coordinators.
Accurate SLP coding avoids payment delays and supports resident care.
5. Leverage Technology and Automation
Use alerts and validation tools to catch missing or mismatched data.
Apply PDPM modeling tools to test “what-if” scenarios and predict payments.
Automation improves accuracy and speeds up claim submission.
6. Enhance Clinical and Billing Team Collaboration
Use a PDPM pre-billing checklist before submitting claims.
Review denials together to identify errors and improve processes.
Strong teamwork ensures smooth workflows and fewer denials.
Conclusion
Mastering PDPM requires accuracy, teamwork, and proactive management. Outsourcing SNF billing and coding services to experts ensures:
Accurate ICD-10 coding
Proper MDS and therapy documentation
Timely claim submission
Optimized reimbursement
With EHR integration and professional support, SNFs can focus on patient care while maximizing revenue under PDPM
FAQs
Q1. Are “what-if” PDPM scenarios useful? Yes, they help predict reimbursement and identify missed opportunities before submission.
Q2. Does PDPM apply to all Medicare SNF patients? Yes, it applies to Medicare Part A patients under the Prospective Payment System.
Q3. Are interdisciplinary meetings important? Absolutely. They keep documentation, coding, and care plans aligned.
Q4. Why are NTA points important? Properly documented NTA points can significantly increase reimbursement.
Read detailed blog: https://www.247medicalbillingservices.com/blog/mastering-pdpm-tips-to-optimize-snf-coding-and-claims
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