PDPM Deep Dive: How Accurate Coding and Data Drive Reimbursement Success
For skilled nursing facilities (SNFs), accurate reimbursement is essential for both financial stability and high-quality patient care. The Patient-Driven Payment Model (PDPM) has transformed how Medicare reimburses SNFs by focusing on each resident’s clinical characteristics, conditions, and care needs instead of therapy minutes alone.
While this approach better aligns payment with patient complexity, it also increases the importance of precise coding and thorough documentation. Health Advisory Partners by Aegis Therapies® (HAP) helps facilities navigate PDPM with expert consultation and tools like our reimbursement calculator, ensuring every service provided is accurately captured and reimbursed.
Why PDPM Accuracy Matters
Under PDPM, reimbursement rates are determined by resident-specific HIPPS codes. These codes are derived from a combination of clinical data points, including:
Primary diagnosis and comorbidities
Functional status and cognitive patterns
Presence of specific conditions or services such as IV therapy or ventilator care
Swallowing disorders, pressure ulcers, and other complex needs
Because payment is directly tied to the complexity of care, any missed or incomplete documentation can lower your facility’s reimbursement, sometimes by hundreds of dollars per patient, per day. For example, failing to code a qualifying comorbidity might drop a resident into a lower Case Mix Index (CMI) category, reducing the daily rate despite the fact that your team is providing a higher level of care.
Accurate PDPM coding helps ensure you are reimbursed for the care you are actually delivering, not a reduced version of it.
Our Approach to PDPM Accuracy
Many skilled nursing facilities rely on automated scrubbers to find coding or documentation issues, but these tools have limitations. Software can flag potential errors, but it can’t interpret nuances, uncover hidden opportunities, or provide actionable guidance. That’s why HAP takes a “No Scrubbers” approach.
HAP emphasizes the human touch. Experienced reviewers work directly with your team, analyzing each resident’s data and identifying coding opportunities that technology alone might miss. HAP finds potential adjustments in an average of 35% of reviewed cases, ensuring documentation reflects the care provided.
This approach follows the Six Steps to Accuracy:
Provide detailed analysis of current performance
Agree to network collaboration
Review 100% of PDPM reimbursed assessments
Uncover exceptions in real time
Take immediate action
Circle back for quality control
By combining hands-on expertise with repeatable processes, HAP helps facilities achieve accurate reimbursement while strengthening documentation and turning PDPM compliance into both a strategic and financial advantage.
The HAP PDPM Coding Consultation Process
At HAP, we work closely with facilities to help ensure they capture a complete and accurate picture of each resident’s needs and services. Our PDPM Coding Consultation is a streamlined, hands-on process designed to uncover missed opportunities and enhance reimbursement accuracy.
Here’s how it works:
Submit Resident Details
Once your MDS coding is complete, send your HAP reviewer an email with identifying resident information and any relevant scanned documents not stored in your EMR, such as hospital discharge paperwork or physician notes.Receive Expert Review and Recommendations
Your dedicated reviewer will analyze your coding and provide:Specific recommendations for adjustments
The rationale behind each suggestion
An estimate of the impact on your Case Mix Index (CMI) and reimbursement
Access Monthly Impact Reports
Every month, you’ll receive a comprehensive Monthly Impact Report showing the measurable financial improvements from our collaboration. These reports give you a clear view of your facility’s PDPM performance and highlight additional opportunities for optimization.
By combining personalized review with data-backed reporting, our consultation process equips your team to strengthen documentation practices and improve long-term revenue accuracy.
Best Practices for PDPM Success
Here are a few best practices that consistently drive better PDPM outcomes:
Prioritize thorough admission assessments. The first days are critical for capturing accurate resident data.
Promote interdisciplinary communication. Nurses, therapists, and physicians should share updates to help ensure all conditions are documented.
Train staff regularly on PDPM updates. Regulations and interpretations evolve, so education must be ongoing.
Leverage data tools. Use the reimbursement calculator regularly to anticipate and plan for financial impacts.
Review MDS data before submission. A final audit can catch costly omissions before they affect payment.
When combined, these strategies help facilities optimize reimbursement without sacrificing the quality and integrity of resident care.
The PDPM Reimbursement Calculator
Even with expert coding support, SNFs need a way to forecast reimbursement and evaluate coding decisions. HAP’s reimbursement calculator simplifies this complex process, providing fast, accurate payment projections using 100% publicly available CMS data.
Model “what-if” scenarios, such as adding a qualifying comorbidity or adjusting a discharge date, to understand financial impact. Integrating the calculator into planning helps you make informed decisions, optimize budgeting, and identify documentation or training needs.
PDPM in Action: A Strategic Approach
To illustrate, imagine a resident admitted after a hospital stay for pneumonia, also presenting with diabetes and moderate cognitive impairment. Without thorough documentation, the diabetes diagnosis might be omitted from the MDS, resulting in a lower CMI score and reduced payment.
With HAP’s PDPM coding consultation, that missing diagnosis is identified, justified with supporting documentation, and added to the MDS. Using the reimbursement calculator, the facility can then see exactly how that change impacts the HIPPS code and daily reimbursement rate, often resulting in hundreds of additional dollars per day for the same level of care already being provided.
This combination of expert review and data-driven forecasting turns PDPM from a challenge into a predictable, manageable process that supports both compliance and financial health.
Turning PDPM from a Challenge into an Opportunity
PDPM has changed the game for skilled nursing reimbursement, but with the right strategy, it can be a powerful tool for aligning care quality with financial stability. At HAP, we provide the guidance, training, and tools you need to:
Capture every billable aspect of resident care
Avoid costly undercoding and missed revenue opportunities
Forecast financial performance with accuracy
Maintain compliance while delivering exceptional care
Our goal is simple: help your facility succeed under PDPM so you can focus on what matters most—your residents.
Ready to optimize your PDPM results? Contact HAP today to learn how our coding consultations and reimbursement calculator can help your facility capture every dollar it earns while maintaining the highest standards of care.
Health Advisory Partners welcomes all persons in need of its services and does not discriminate on the basis of age, disability, race, color, national origin, ancestry, religion, gender identity, sexual orientation or source of payment. Interpreter Services are available at no cost. Please visit Health Advisory Partners for assistance. Servicios de interpretación están disponibles sin costo. Visite su sucursal local de Aegis Therapies para recibir asistencia. 我们提供免费传译服务。请探访您的本地Aegis Therapies地点以获得协助