PDPM Isn’t Broken - But Your MDS Workflow Might Be

Dhruva Sareen

15 Jun 2025 — 3 min read

Why even the best SNFs are bleeding revenue from missed diagnoses, delayed assessments, and outdated tools - and what leading operators are doing differently.

Ask any MDS coordinator how their week’s going, and you’ll get the same answer: too many charts, not enough time.

In 2025, it’s not unusual for a SNF to serve 40+ short-stay patients a month - each with a complex hospital record spanning 300+ pages. Add in daily assessments, evolving patient conditions, and CMS rules that change annually, and it’s no wonder so many PDPM submissions fall short of the reimbursement they should command.

But here’s the thing: PDPM isn’t the issue. Your data is. Or more specifically - how your team is forced to work with it.

The problem isn’t under-coding. It’s under-resourcing.

Take the first 72 hours after a patient is admitted. This is the most financially consequential window in PDPM. Your team needs to:

Review every hospital doc (H&P, labs, consults, discharge summary)
Capture all co-morbidities, including the 80+ NTA conditions with tripled weightage in the first 3 days
Set the ARD to match the timing of reimbursable triggers (IV fluids, isolation, wound care)
Ensure documentation supports the selected diagnoses
Coordinate with rehab, nursing, and social work to finalize scores

In theory, this is standard operating procedure. In practice? Most SNFs are lucky if the MDS nurse has time to do anything beyond the basics.

The cost of this is staggering. A missed NTA? That’s $300–$1,200 per patient gone. An invalid ARD? Welcome to the default rate - $180/day. Multiply that across 300+ annual admissions and you’re looking at $200K+ in missed revenue, and that’s before we even get into IPA triggers and CMS audits.

Why even experienced MDS nurses are missing the mark

It’s not a skills issue. It’s a systems issue.

In a recent conversation with a clinical reimbursement expert who oversaw PDPM performance for 8 of Hawaii’s top-performing SNFs, the challenges were crystal clear:

Diagnoses buried in dense records: Things like diabetic retinopathy or interstitial lung disease often appear only once - a line in a specialist’s note or an old discharge summary. Easily missed. Easily reimbursable.
Manually reviewing hundreds of pages: MDS teams are expected to catch every detail, but most don’t have the hours - or software - to make that feasible.
Inconsistent documentation from referring hospitals: Critical notes (e.g., “care provided in isolation”) may be missing, misfiled, or sent via fax.
Training gaps & staff churn: Most MDS nurses are thrown into the fire without deep PDPM training. The average tenure? Just over a year.

Facilities that consistently outperform on PDPM do so because they’ve operationalized for accuracy. They have the oversight, training, and most importantly — tools — to support their staff.

What Top-Performing SNFs Are Doing Differently

The best operators aren't trying to hire their way out of the problem—they’re rethinking process. Specifically:

Frontloading visibility

They ensure hospital packets are fully available and searchable by day one. That means pulling full discharge summaries, IV records, and consults without delays.

Systematic NTA detection

Rather than relying on memory or static checklists, they use logic or tools that flag likely NTAs based on keywords, meds, vitals, and prior diagnoses.

Centralized ARD/IPA oversight

They track all ARDs and potential IPA triggers in a shared dashboard or workflow tracker, so no opportunity slips through the cracks.

Validation before submission

Before hitting submit, a second set of eyes—or an automated validator—checks for missing high-weight diagnoses, conflicting documentation, or lookback window mismatches.

The result? More accurate claims, fewer denials, and significantly higher revenue capture per resident.

What’s Really at Stake?

Let’s put some rough numbers to it.

For a 100-bed SNF with moderate short-stay volume:

Missed NTAs could cost $900–1,200 per case
Incorrect ARDs or missed IPAs could result in $250–500 per case lost
Under-coded diagnoses affect reimbursement for the entire stay, sometimes dropping payment bands by $100+ per day

Multiplied across a year, that’s $250K–500K in revenue left on the table—not to mention the time spent chasing denials, fighting audits, or explaining variances to finance.

You don’t need another compliance consultant. You need a co-pilot.

The smartest facilities have redefined the MDS function as a strategic lever, not a paperwork burden. They’re not just compliant — they’re outperforming.

If your MDS team is still: