PDPM

PDPM replaced RUG-IV, the 66-group system Medicare used for skilled nursing facility stays from October 2010 to September 2019. Instead of placing a stay in one group, PDPM classifies the patient separately for each case-mix adjusted component: physical therapy, occupational therapy, speech-language pathology, nursing and non-therapy ancillaries. The classification comes from the Minimum Data Set. Only two assessments produce a payment code under PDPM: the initial 5-day PPS assessment and the optional interim payment assessment, which the facility can complete at any point in the stay.

The claim carries the result as a five-character HIPPS code on a revenue code 0022 line of a type of bill 21X claim. The first position holds the shared PT and OT group, the second speech-language pathology, the third nursing, the fourth non-therapy ancillaries, and the fifth the assessment indicator. The daily rate is not flat across the stay. A variable per diem adjustment keeps the PT and OT rates at full value for days 1-20 and steps them down every seven days after that, and pays the non-therapy ancillary component at three times its rate for days 1-3.

Interrupted stays are where the billing goes wrong. If a patient leaves Part A coverage and returns to the same facility by 11:59 p.m. on the third consecutive non-covered day, it is the same stay: no new assessment is required and the variable per diem schedule does not reset. A return after that window, or to a different facility, is a new stay. Billing a return as a new stay, or a new stay as a continuation, puts the wrong day count and the wrong rate on every day that follows.