Stop Leaving Money on the Table: 5 Hidden PDPM Triggers Most SNFs Miss

Back in 2019, the PDPM (Patient-Driven Payment Model) fundamentally changed how skilled nursing facilities (SNFs) get reimbursed under Medicare. On the face of it, the new system of reimbursement promised a holistic view of patients (and a lot more revenue for SNFs).

Yet, 5+ years later, many facilities continue to lose thousands of dollars per resident by missing key triggers that boost PDPM payments. Let’s uncover the five most common triggers SNFs overlook and how catching them can significantly improve revenue and operational efficiency.

Why Missed PDPM Triggers Cost SNFs Big

Under PDPM, reimbursement depends directly on accurate clinical documentation. Even small oversights can lead to substantial financial losses - sometimes hundreds of dollars per resident-day. Facilities consistently capturing these triggers not only maximize revenue but also demonstrate higher-quality, better-documented care.

Here are the five most overlooked PDPM triggers that facilities routinely miss:

1. SLP: The Silent Revenue Booster

Most Commonly Missed: Cognitive impairments, swallowing disorders, and mechanically altered diets.

An analysis by Zimmet Healthcare found SLP coding errors in nearly 38% of PDPM assessments. Often, facilities fail to properly document cognitive impairments through timely BIMS (Brief Interview for Mental Status) interviews or overlook swallowing issues indicated in Section K.

For example, failing to accurately document mild cognitive impairment or dysphagia can downgrade a resident’s SLP category, losing up to $30 per patient-day.

Quick Fix: Ensure speech therapists and nurses complete timely, accurate assessments. Use automated reminders to avoid missed BIMS assessments.

[Source: Zimmet Healthcare]

2. Nursing Component: The Depression and Isolation Pitfalls

Most Commonly Missed: Depression indicators, restorative nursing programs, and proper isolation documentation.

Depression alone can significantly increase nursing case-mix scores, yet it's commonly overlooked. Many facilities also fail to document isolation properly, missing the lucrative "Extensive Services" category.

Consider this scenario: A resident with documented sepsis wasn’t correctly flagged under "Septicemia," causing the facility to miss nearly $60/day in reimbursement.

Quick Fix: Train staff on MDS coding nuances, emphasizing depression and isolation criteria. Consider regular audits to catch documentation gaps early.

[Source: CMS PDPM Audit Reports]

3. PT/OT: The Surgical and Functional Score Slip-ups

Most Commonly Missed: Incorrect surgical procedure coding and inaccurate Section GG scoring.

While PT and OT have fewer outright errors, miscoding surgeries or incorrectly assessing functional status can be financially detrimental. For instance, improperly categorizing a hip fracture surgery as "Other Orthopedic" instead of "Major Joint Replacement" can cost over $50 per day.

Similarly, inaccurately high functional scoring (due to documentation gaps) pushes residents into lower-paying categories.

Quick Fix: Cross-check surgical procedures with ICD-10 codes diligently, and validate Section GG scoring through interdisciplinary discussions.

[Source: PDPM Consultant Insights]

4. NTA: Hidden Comorbidities Are Costly

Most Commonly Missed: Malnutrition, diabetic complications, morbid obesity, and IV medication usage.

Non-Therapy Ancillaries (NTA) scoring is heavily dependent on accurately documenting comorbidities. Facilities often underreport conditions like malnutrition or diabetic complications, each worth valuable NTA points.

A single missed diabetic complication, like retinopathy, can reduce the daily rate by over $20. Over an average 20-day stay, that's $400 lost per resident.

Quick Fix: Implement thorough intake documentation practices and regular chart audits to ensure all comorbidities get recorded correctly.

[Source: MDS Accuracy Reports]

5. Interim Payment Assessments (IPAs): Missed Opportunities

Most Commonly Missed: Failing to initiate IPAs after significant changes in resident condition.

Many facilities hesitate to perform optional IPAs due to perceived administrative burdens. However, failing to capture significant resident changes - such as new isolation, IV medication, or enteral feeding - can cost SNFs significantly.

Triggering an IPA at the right moment can boost reimbursement by $40-60 per day or more, depending on the resident’s new care needs.

Quick Fix: Establish clear triggers and workflows for initiating IPAs, ensuring clinical changes quickly translate into proper reimbursement.

[Source: LeadingAge PDPM Updates]

How to Catch These Triggers Consistently

• Strengthen Documentation Processes: Use admission checklists and software-driven documentation reminders.
• Enhance Interdisciplinary Communication: Encourage regular interdisciplinary team (IDT) meetings focused on PDPM coding accuracy.
• Automate Where Possible: Adopt software solutions that flag missing documentation and coding opportunities proactively.
• Train Regularly: Continuous staff training on PDPM updates and documentation best practices ensures accuracy.

Conclusion: Every Detail Counts

PDPM coding accuracy is more than compliance - it's about financial health and care quality. Small documentation misses add up quickly, directly affecting your facility’s bottom line.

Stop leaving money on the table. By proactively addressing these commonly overlooked PDPM triggers, SNFs can optimize reimbursement and reinvest in improving care.

[Ready to automate PDPM triggers? Try Nanonets Health PDPM automation today.]