PDPM At-a-Glance Tool-PDPM At-a-Glance Tool

PDPM At-a-Glance Tool

Pdf Summary

The Patient-Driven Payment Model (PDPM) sets a Medicare Part A skilled nursing facility payment rate using the 5-Day PPS assessment. The rate combines five case-mix components—Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP), Nursing, and Non-Therapy Ancillary (NTA)—plus a non-case-mix component. An optional Interim Payment Assessment (IPA) can change the rate during the stay.<br /><br />The assessment produces a five-character HIPPS billing code: the first character identifies the shared PT/OT case-mix group, followed by the SLP, Nursing, and NTA groups; the fifth character indicates whether the code is for an IPA or the 5-Day assessment. PT and OT use the same group, but their payment levels differ.<br /><br />Classification relies on clinical conditions, diagnoses, services, cognitive status, and Section GG functional scores. Nursing and PT/OT scoring use assistance levels recorded for selected activities. SLP classification considers factors such as acute neurologic conditions, relevant comorbidities, cognitive impairment, swallowing disorders, and mechanically altered diets. NTA points are assigned for qualifying diagnoses, treatments, and services; the total determines one of six groups, from NF (zero points) to NA (12 or more points).<br /><br />The document also explains the Administrative Level of Care Presumption. A qualifying group on the initial 5-Day assessment presumes the resident meets SNF level-of-care requirements through that assessment’s reference date. Qualifying groups include specified PT/OT and SLP groups, any Nursing group in Extensive Services, Special Care High or Low, or Clinically Complex, and NTA group NA. Only one qualifying group across the components is needed. The presumption applies only when the SNF admission directly follows discharge from the prior hospital stay; nonqualifying groups do not by themselves establish that the resident fails to meet level-of-care requirements.<br /><br />The guide reflects CMS changes in the FY 2027 SNF PPS Final Rule and is informational, not legal or regulatory advice.

Keywords

Patient-Driven Payment Model

PDPM

Medicare Part A

skilled nursing facility

5-Day PPS assessment

HIPPS billing code

case-mix components

Interim Payment Assessment

Section GG functional scores

SNF level-of-care presumption