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The Patient-Driven Payment Model (PDPM) is the Medicare Part A payment system CMS developed to better align SNF reimbursement with each resident’s true clinical needs. Rather than basing payment on therapy minutes, PDPM uses a resident’s diagnoses, comorbidities, functional status, and clinical complexity to determine case-mix groups across PT, OT, SLP, Nursing, and Non-Therapy Ancillary components. This shift places greater emphasis on clinical accuracy, interdisciplinary documentation, and high-quality intake processes.

Because PDPM payment is shaped from the very first assessment, even small gaps—an unspecified ICD-10 code, a missed comorbidity, or inconsistent GG scoring—can create significant revenue leakage. Many SNFs still leave money on the table simply because essential clinical details never make it into the MDS.

To strengthen PDPM accuracy and protect reimbursement, SNFs need disciplined workflows, rigorous documentation standards, and operational oversight that consistently catches errors before they affect billing. Below are the top strategies that deliver the largest financial impact.

SNFs that succeed under PDPM are those that maintain consistent documentation workflows and strong clinical validation processes. Cascala supports this work by giving teams the real-time operational insight needed to catch misses before they impact reimbursement.

1. Strengthen ICD-10 Specificity—Small Errors, Big Revenue Impact

ICD-10 coding is the backbone of PDPM accuracy, yet it remains one of the largest sources of avoidable revenue loss.

Common pitfalls that lower reimbursement

• Use of unspecified diagnoses
• Missing surgical codes that should drive the PT/OT category
• Incorrect linkages between hospital documentation and SNF coding
• Failure to validate that the primary diagnosis maps to a PDPM-supported clinical category
  
  

High-impact improvements

• Conduct a hospital-to-SNF diagnosis reconciliation process before admission
• Maintain clinical-category–specific ICD-10 resources for staff
• Audit unspecified or invalid codes weekly
• Ensure operative notes are captured and coded on Day 1
  
  

Accurate ICD-10 coding sets the tone for the entire stay—and prevents immediate underpayment.

2. Capture Every Comorbidity That Impacts PDPM Scores

Missed comorbidities remain one of the most consistent drivers of PDPM underpayment.

Comorbidities frequently overlooked

• Diabetes with complications
• Congestive heart failure and chronic pulmonary diseases
• Major depressive disorder
• Peripheral vascular disease
• Pressure injuries (if not staged or documented thoroughly)
  
  

Tactics that work

• Use a structured comorbidity checklist within the first 24 hours
• Review hospital documentation, past records, and medication lists
• Train teams to look for clinical clues that indicate underlying chronic conditions
• Hold a brief “comorbidity huddle” immediately following intake
  
  

Even a single missed condition can change NTA points or the nursing component—and meaningfully reduce reimbursement.

3. Maximize NTA Points by Capturing Complexity Early

The Non-Therapy Ancillary (NTA) component is one of the highest-value levers in PDPM—and one of the easiest areas to miss.

Why SNFs lose NTA revenue

• Comorbidities not properly linked to supporting documentation
• Overlooked high-cost medications or therapies
• Incomplete capture of ongoing clinical complexity
  
  

How to fix it

• Build NTA-first workflows into nursing admission processes
• Use pharmacy records to identify conditions tied to higher NTA weights
• Confirm that wound care, IV meds, isolation status, and respiratory needs are fully documented
• Trend NTA scores over time to identify persistent gaps
  
  

Because NTA points are tripled in the first three days, early precision is critical.

4. Improve MDS Accuracy Through Real-Time Validation

The MDS determines PDPM payment, but frontline teams often face time pressure, inconsistent inputs, or incomplete information.

Common MDS issues that reduce reimbursement

• Misaligned GG scoring across disciplines
• Inaccurate cognitive codes or missed BIMS assessments
• Late submissions or corrections
• Missed surgical procedures or comorbidities not reflected in the MDS
  
  

Solutions that make the biggest difference

• Hold brief GG consensus huddles
• Use real-time alerts for missing or inconsistent MDS fields
• Implement structured audits for high-variance items
• Standardize response workflows for OSA audits
  
  

Accurate, interdisciplinary MDS inputs eliminate variation—and protect PDPM integrity.

5. Elevate Intake Quality to Improve PDPM, QRP, and VBP Data

Intake is often the single most influential step in the PDPM process—but also the most inconsistent.

Intake vulnerabilities

• Missing hospital notes, surgical summaries, or progress reports
• Medication lists that don’t match diagnoses
• Incomplete verification of comorbidities
• Unclear or missing surgical details
  
  

High-performance intake standards

• Use a standardized pre-admission documentation checklist
• Cross-reference documentation before MDS Day 1
  
  
• Validate diagnoses and surgical history directly with providers when unclear
• Require complete document sets prior to confirming admission

Intake quality shapes PDPM accuracy, QRP/VBP integrity, and even readmission outcomes.

6. Conduct “Money on the Table” PDPM Audits

Regular, rapid audits can reveal immediate revenue opportunities.

Audit focus areas

• ICD-10 specificity
• Missing comorbidities
• NTA conditions not captured
• GG scoring variation
• Incorrect surgical linkage
• Residents billed under a lower CMG than documentation supports
  
  

Why it works

These audits identify real dollars left unclaimed and help leadership understand whether issues

7. Use Operational Analytics to Monitor PDPM Performance

Operational analytics give SNFs visibility into patterns that would otherwise go unnoticed.

PDPM metrics worth monitoring

• Percentage of unspecified ICD-10 codes
• Average NTA points by diagnosis vs. benchmark
• GG score variation by clinician
• Surgical capture accuracy
• Time-to-complete for MDS submissions
• CMG trends by referral source
  
  

With real-time visibility, PDPM accuracy becomes a predictable, repeatable operational strength—not an exercise in reactive correction.

The Bottom Line

PDPM precision is directly tied to financial stability. When SNFs capture diagnoses accurately, identify all comorbidities, validate GG and MDS entries, and implement consistent intake workflows, they not only prevent revenue loss but strengthen quality, staffing stability, and resident outcomes.

Ready to improve PDPM accuracy and eliminate preventable revenue loss?

See how Cascala helps SNFs strengthen documentation, streamline intake, and capture the full reimbursement they’re owed — contact us or schedule a demo.

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