PDPM for the Business Office: Assessment and Coding

We’ve been busy working with our skilled nursing facility partners to prepare for the Patient Driven Payment Model (PDPM), a new case-mix system for classifying skilled nursing facility (SNF) patients beginning October 1, 2019. Not sure what information to provide your SNF office staff about the upcoming changes? Share this information on assessment and coding to help prepare your SNF business office for a successful transition:

PDPM Assessment Schedule

There will be three SNF Prospective Payment System (PPS) assessments under PDPM: the 5-day Assessment, the Interim Payment Assessment (IPA) and the PPS Discharge Assessment. The 5-day assessment and the PPS Discharge Assessment are required. The IPA is optional. It will be completed when the patient has undergone a clinical change that would require a new PPS assessment.

The 5-day Assessment will pay for all covered Part A days until the Part A discharge (except in cases when an IPA is completed). The IPA will pay for all days from the Assessment Reference Date of the IPA through the part A discharge (unless another IPA assessment is completed).

During the changeover from RUG-IV to PDPM, all current SNF patients who were admitted prior to the PDPM effective date (October 1, 2019) must receive a new IPA under the PDPM, even if they were already assessed under RUG-IV. This is required in order to obtain a Health Insurance Prospective Payment System (HIPPS) code for billing purposes.

ICD-10 Coding

There are two ways ICD-10 codes will be used under PDPM. First, providers will be required to report on the MDS the patient’s primary diagnosis for the SNF stay. Each primary diagnosis is mapped to one of 10 PDPM clinical categories, representing groups of similar diagnosis codes, which is then used as part of the patient’s classification under the PT, OT and SLP components.

ICD-10 codes are used to capture additional diagnoses and comorbidities that the patient has. These can factor into the SLP comorbidities for classification of patients under the SLP component. The codes are also used for determination of the Non-Therapy Ancillary (NTA) comorbidity score that is used to classify patients under the NTA component.


PDPM is the first significant change to the SNF reimbursement model in 20 years. Our skilled nursing facility division is staying up-to-date on all things PDPM-related, helping our partners prepare for a successful transition this October. Stay tuned for our next PDPM post on the new interrupted stay policy.

For additional details on the Patient Driven Payment Model, please visit the CMS PDPM Page

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