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PDPM Snapshot: Answers at a Glance

June 20, 2019
Documentation, Billing, & Coding By Kay Hashagen, Senior Consultant

How do you get  Patient-Driven Payment Model (PDPM) reimbursement? If there is no speech, will the patient forfeit that component? Do you know the base rate? Is the reimbursement less after day 20? These are some of the recent questions that have been asked by those who are working in the Skilled Nursing Facility (SNF) setting.

While it is true that the software used by your company should calculate the PDPM reimbursement Case-Mix Index (CMI), it is also crucial to know the foundation of the computation.

The payment rate for each day of the stay, in the SNF, is obtained by adding the six Patient-Driven Payment Model (PDPM) components: Nursing, Non-Therapy Ancillary (NTA), Physical Therapy (PT), Occupational Therapy (OT), and Speech Language Pathology (SLP), plus the Non-Case-Mix component. This PDPM rate will cover for the entire SNF stay and will only change if an optional Interim Payment Assessment (IPA) is completed. Under Medicare Part A, every patient in the SNF will be eligible to receive all the PDPM components whether or not the patient is receiving the service.

What is the Base Rate?

Every PDPM component has a base rate, set by The Centers for Medicare & Medicaid Services (CMS), which is a fixed amount for every fiscal year and classified into urban or rural categories depending on the SNF location. This base rate is the starting point for the calculation of the Nursing, NTA, PT, OT and SLP components. Each of the five components include a specific methodology for obtaining the Case-Mix Group (CMG) which is based on patient characteristics as coded on the Minimum Data Set (MDS). Every CMG for each of the five components has an equivalent CMI. The respective PDPM base rate is then multiplied by that component’s CMI. Remember that the non-case-mix component has either an urban or rural base rate and does not vary by patient characteristics. This is for room and board and other capital expenses.

What is the Variable Per Diem (VPD)?

The Variable Per Diem (VPD) is a scheduled adjustment factor applicable to the NTA, PT and OT components. For the NTA component, the VPD is applied to days 1 to 3 of the SNF stay. This means that the base rate multiplied by the CMI, will then be multiplied by the VPD which is 3, and this is the NTA component for the first 3 days of the SNF stay. For the PT and OT components, the VPD decreases 2% every 7 days after day 20 of the SNF stay.

Additionally, the Nursing component will receive an 18% add-on if the patient has a diagnosis of AIDS/HIV that is reported on the claim as ICD-10 B20 but not coded on the MDS.

There is a PDPM Default Code which is ZZZZZ, utilized for late assessments. The PDPM Default Code represents the sum of the lowest per diem rate under each PDPM component plus the non-case-mix component. If the PDPM Default Code is used, the VPD schedule must still be followed.

Be aware that missing MDS data will not produce a PDPM HIPPS code. For example, no Brief Interview for Mental Status (BIMS) and staff cognitive assessment. Thus, there will be no basis for billing and the provider would be considered liable.

Looking for more information? Purchase our PDPM Rate Chart or download our infographic on How to Code Section GG.

LWCI offers products and services that can be tailored to your needs as you transition to PDPM. Register for one of our upcoming PDPM webinars or visit our store to download a past webinar on-demand.



 For more information, contact Kay Hashagen at 410-777-5999 or email

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