Mastering PDPM: Tips to Optimize SNF Coding and Claims

Have you wondered how the Patient-Driven Payment Model (PDPM) is changing the way Skilled Nursing Facilities (SNFs) get reimbursed? Unlike the old RUG-IV system, PDPM rewards facilities based on a resident’s clinical complexity rather than the number of therapy minutes provided. In fact, any missing or incomplete documentation can lead to lost revenue, claim denials, or costly audits which makes precision more critical than ever.

As PDPM continues to evolve, the stakes are getting even higher. The FY 2026 final rule introduces 34 ICD-10 mapping updates effective October 1, 2025, adjusts payment rates by 3.2% plus market basket updates, removes certain Social Determinants of Health items from the MDS, and eliminates the Health Equity Adjustment in the SNF Value-Based Purchasing program.

But the biggest challenge that arises is how SNFs can stay ahead and master PDPM? This blog will guide you through practical strategies that SNFs should follow to optimize coding and claims to master PDPM.

Tips to Optimize SNF Coding and Claims

Optimizing SNF coding and claims under PDPM is all about accuracy, teamwork, and attention to detail. When SNFs apply structured processes from admission to discharge, they can improve compliance, minimize denials, and ensure proper reimbursement. The following tips explain precisely how to master PDPM through smarter documentation, coding, and collaboration:

1. The Critical Admission and 5-Day MDS Assessment

• Structured Admission Workflow

The first five days after a resident’s admission set the foundation for PDPM payment. Therefore, every facility should have a clear admission workflow in which nurses, therapists, and MDS coordinators collaborate from the outset. When everyone reviews the same data in real time, it prevents missing details and ensures that all documentation supports accurate coding and reimbursement.

• Accuracy in Section GG and Documentation

Section GG scores measure a resident’s ability to perform daily tasks such as dressing, bathing, and walking. As these scores influence payment levels, they must be recorded carefully and supported by clinical notes. In fact, regular reviews of Section GG entries help confirm that the information reflects the resident’s actual performance and aligns with the MDS data.

• Timely Interim Payment Assessments (IPAs)

If a resident's medical condition or care needs change, an IPA may be required. In fact, establishing clear criteria for when to complete an IPA ensures payment continues to match the level of care provided. Moreover conducting IPAs promptly demonstrates compliance and helps facilities maintain reimbursement accuracy throughout the stay.

2. ICD-10 Strategy and Comorbidity Capture

• Selecting the Right Primary Diagnosis

The primary diagnosis determines how a patient is categorized under PDPM. To ensure accurate classification, coders should always use specific ICD-10 codes instead of vague or general ones. In fact, staying up to date with the latest CMS mapping files helps avoid errors and ensures correct payment grouping.

• Comorbidity Identification

Many residents have multiple medical conditions that affect their care needs and reimbursement levels. In fact, identifying all relevant comorbidities, such as diabetes, heart disease, or stroke, ensures that the MDS reflects the resident’s true clinical complexity. This information directly impacts the Nursing, NTA, and SLP components of PDPM.

• Maintaining a High-Impact Code List

Every facility should maintain a current list of high-impact ICD-10 codes that commonly affect PDPM categories. In fact, regularly updating this list and training staff on its use helps improve coding accuracy and consistency. It also reduces time spent searching for codes and minimizes claim errors.

3. Maximizing Non-Therapy Ancillary (NTA) Points

• Early Screening for NTA Qualifiers

As NTA points are most valuable during the early part of the stay, identifying qualifying conditions during admission is essential. Screening residents for services such as IV medication, complex wound care, or isolation precautions helps ensure these factors are identified promptly. This proactive approach increases accuracy in NTA scoring.

• Ongoing Monitoring for Clinical Changes

Patient conditions can change quickly, so daily reviews of clinical status are essential. In fact, staff can update the MDS in real time by tracking new diagnoses, medications, or treatments. This ongoing monitoring ensures that all NTA-related factors are accurately reflected and reimbursement remains accurate.

• Documenting with Precision

Every NTA condition must be clearly documented in the medical record and entered correctly in the MDS. Using standardized documentation formats helps ensure nothing is overlooked. In fact, consistent and precise documentation supports compliance and prevents potential denials during audits.

4. Speech-Language Pathology (SLP) Component Optimization

• Early SLP Screening

Early identification of speech or swallowing issues ensures residents receive timely care and accurate PDPM classification. Screening all new admissions for communication or swallowing risks within 48 hours allows therapy teams to act quickly. This practice improves both patient outcomes and reimbursement accuracy.

• Alignment of Documentation and Coding

The diagnoses recorded in the SLP component, such as dysphagia or cognitive impairment, must match the ICD-10 codes in the record. Any inconsistency between documentation and coding can affect payment or lead to claim delays. Therefore, it is crucial to ensure alignment, as it helps maintain compliance and accurate SLP scoring.

• Collaborative Case Review

Regular case reviews among SLPs, nurses, and MDS coordinators help ensure that all therapy notes, care plans and coding entries are accurate and match. This collaboration reduces errors and promotes consistent, complete documentation across departments. It also supports a more holistic approach to patient care.

5. Utilizing Technology and Automation

• Integrated EHR and MDS Systems

Integrating the EHR with MDS software helps reduce manual data entry and eliminates transcription errors. When systems communicate seamlessly, it ensures that patient information is transferred accurately and securely across departments. This integration supports both compliance and faster claim submission.

• Automated Alerts and Validation Tools

Automated alerts flag missing or mismatched data before it becomes a problem in order to prevent issues from arising. For example, if a diagnosis doesn’t align with an MDS entry, the system can notify staff immediately. These built-in checks improve accuracy and prevent costly billing errors.

• Using PDPM Modeling Tools

PDPM modeling tools enable administrators to test the impact of changes in coding or clinical data on reimbursement. In fact SNFs can identify potential improvements in coding accuracy by running "what-if" scenarios. This proactive approach helps facilities optimize both compliance and financial performance.

6. Enhancing Collaboration Between Clinical and Billing Teams

• PDPM Pre-Billing Checklist

Before submitting a claim, using a PDPM-specific checklist ensures that all details are accurate and complete. This includes verifying diagnosis codes, therapy minutes and MDS entries. A final review step like this reduces rework and speeds up the payment process.

• Joint Review of Denials

When denials occur, clinical and billing teams should review them together to identify the cause. In fact, working collaboratively ensures that both documentation and billing processes improve. Over time this shared learning reduces errors and enhances financial performance.

• Ongoing Communication Channels

Maintaining open communication between departments promotes efficiency. In fact, shared dashboards, regular updates and case discussions keep everyone aligned. This continuous collaboration helps prevent misunderstandings and improves workflow transparency.

Conclusion

Undoubtedly, mastering PDPM requires a strategic combination of clinical accuracy, meticulous documentation, and proactive financial management. Now, all this can be achieved as a one-stop solution by outsourcing SNF billing and coding services to 24/7 Medical Billing Services. These specialized professionals bring deep knowledge of evolving CMS regulations, PDPM updates, and coding complexities that can easily be missed in-house.

In fact, facilities can identify overlooked NTA qualifiers, validate therapy and nursing components, and ensure claims are submitted accurately and on time by utilizing their expertise. Ultimately, combining strong internal processes with external PDPM expertise ensures SNFs not only optimize coding and claims but also achieve long-term operational efficiency and improved revenue cycles.

FAQs

Q1. Is there a benefit to running PDPM “what-if” scenarios?

Modeling scenarios helps predict reimbursement and identify missed opportunities before submission.

Q2. Does PDPM apply to all Medicare patients in SNFs?

PDPM applies to Medicare Part A SNF patients covered under the Prospective Payment System.

Q3. Are interdisciplinary meetings crucial for the success of PDPM?

Regular huddles ensure documentation, coding, and care plans are aligned.

Q4. What role do Non-Therapy Ancillary points play in PDPM?

NTA points can significantly increase reimbursement if qualifying conditions are documented early.