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Successful Billing Under PDPM

With October behind us, we’re faced with the most dreaded task since the Payment Driven Payment Model was implemented: billing. How are the claims different under PDPM? How do we ensure that our claims are clean and errorless? Let’s look at a couple of the facts that are imperative to facilities for successful billing under PDPM.

PDPM has only TWO mandatory assessment types:

Five-day Scheduled PPS Assessment and PPS Discharge Assessment are the only mandatory assessments under PDPM. There are TWO optional assessments, as well. These are the Interim Payment Assessment (IPA) and the Optional State Assessment (OSA). These are to be used at the discretion of the facility. The IPA is to be utilized when a patient has a significant change in status. The OSA is required for states to bill Medicaid under the RUGS-III and RUGS-IV models until September 30, 2020. CMS will no longer support legacy payment models after that date.

Concurrent and Group Therapy Limits:

Under PDPM, facilities must ensure that therapy providers do not exceed 25% of the patient’s therapy service in group or concurrent billing for the entire length of stay. Therapy software should aid in tracking this requirement and reporting will be required on the PPS Discharge Assessment.


CMS has established a new algorithm to accommodate the new payment groups under PDPM. These five characters are assigned as follows:

Character 1: PT/OT Payment Group

Character 2: SLP Payment Group

Character 3: Nursing Payment Group

Character 4: NTA Payment Group

Character 5: Assessment Indicator

CMS has also provided a crosswalk that can be obtained in the following link:

Return to Provider ICD-10 codes:

It is critical to review the ICD-10 codes that are being recorded on the claim. While CMS reports that only the Primary Medical Diagnosis must not be on the Return to Provider (RTP) list, FISS will be reviewing the entirety of the claim for any non-compliant billing practice. Best practice would be to ensure that NO RTP diagnoses are on the claim.

In addition to these billing changes under PDPM, CMS has also released a statement reporting that they are holding Skilled Nursing claims until late November in order to make further refinements to their claims processing system. Therefore, don’t panic! CMS loves to keep us on our toes. December should provide more clarity as we navigate these muddy waters.

If you have more questions regarding successful PDPM billing, contact us! Turning-Point Consulting is established to empower your facility under PDPM.

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