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

PDPM At-a-Glance Tool

Pdf Summary

The Patient-Driven Payment Model (PDPM), updated in the FY 2026 SNF PPS Final Rule, determines Medicare Part A Skilled Nursing Facility (SNF) payment rates based on a 5-day Patient-Driven Payment System (PPS) assessment. PDPM combines five case-mix components—Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP), Nursing, and Non-Therapy Ancillary (NTA)—with a non-case-mix component to set the total rate for a resident's entire stay. Optional Interim Payment Assessments (IPA) may adjust this rate during the stay.<br /><br />Key components include:<br /><br />1. PT and OT Case-Mix: Scored using Section GG items assessing functional abilities such as self-care, mobility, and transfers, with scores from 0-4. PT and OT always share the same case-mix group but have different payment indices based on clinical categories such as major joint replacement or medical management.<br /><br />2. SLP Component: Based on presence of swallowing disorders, mechanically altered diets, SLP-related comorbidities (e.g., aphasia, stroke, TBI), and cognitive impairment levels. Case-mix groups determine payment levels with varying relative case-mix indices (CMIs).<br /><br />3. Nursing Component: Classified by nursing function scores from Section GG items and presence of clinical conditions like cerebral palsy, pressure ulcers, respiratory or infectious complications. Categories include clinically complex, special care high/low, extensive services, and nursing rehabilitation with corresponding CMIs.<br /><br />4. Non-Therapy Ancillary (NTA) Component: Scores are assigned using resident conditions, extensive services, and treatments, such as IV feeding, mechanical ventilation, infections, transplants, and various comorbidities. Points from these factors determine the NTA case-mix group and payment index.<br /><br />PDPM HIPPS billing codes are constructed using characters representing PT/OT, SLP, Nursing, NTA case-mix groups, and assessment indicators (5-day or IPA). This model emphasizes resident characteristics and clinical complexity over volume of therapy delivered, aligning payments with patient needs.<br /><br />This summary is informational and not legal or regulatory advice. For detailed scoring, coding, and clinical criteria, refer to CMS PDPM guidelines and the RAI User’s Manual chapter 6.

Keywords

Patient-Driven Payment Model

PDPM

Skilled Nursing Facility

Medicare Part A

Case-Mix Components

Physical Therapy

Occupational Therapy

Speech-Language Pathology

Nursing Component

Non-Therapy Ancillary