Improving Mds Accuracy: Strategies To Maximize Pdpm Reimbursements

By Author: 247 medical billing
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Accurate Minimum Data Set (MDS) assessments are essential for ensuring proper reimbursement under the Patient-Driven Payment Model (PDPM). Every entry in the MDS affects case-mix classification and payment rates. Even a small error can result in revenue loss or compliance risks.

Accuracy is not just the job of the MDS coordinator—it requires teamwork among nurses, therapists, coders, and billing staff. Partnering with a professional medical billing company can help facilities strengthen their processes and reduce costly mistakes.

Here are the key strategies skilled nursing facilities can adopt to maximize PDPM reimbursements:

1. Accurate Diagnosis and Surgical History
Correct use of ICD-10 codes is one of the most important steps in MDS accuracy. If diagnoses or surgical histories are incomplete, residents may fall into lower-paying case-mix groups. Regular chart reviews and collaboration among physicians, nurses, and billing staff ensure accurate coding and optimized reimbursements.

2. Functional Scores (Section GG)
Section GG measures mobility and self-care, both of which drive PDPM ...
... reimbursement. Incomplete or underestimated entries lower payments. Facilities must validate and cross-check data to ensure it reflects actual resident performance.

3. Speech-Language Pathology (SLP) Factors
SLP reimbursement depends on swallowing disorders, cognitive impairment, and diet modifications. Missing entries—such as not coding a mechanically altered diet—can result in lost payments. Coordinated documentation ensures these details are captured.

4. Non-Therapy Ancillary (NTA) Points
NTA points represent clinical complexity, including conditions like HIV/AIDS, IV medications, or multiple comorbidities. Missing just one condition can cause major financial loss. Billing and coding staff must carefully review charts and align MDS entries to capture every qualifying factor.

5. Nursing Component: Depression and Restorative Care
Depression screenings (PHQ-9) and restorative nursing programs must be accurately documented to avoid lower-paying categories. Proper alignment of documentation ensures residents are placed in the right case-mix groups.

6. Special Treatments and Services (Section O)
Dialysis, ventilator care, chemotherapy, and IV medications fall under Section O. Missing documentation reduces payment categories. Structured checklists and cross-verification help capture the full scope of treatments provided.

7. Interim Payment Assessments (IPAs)
When a resident’s condition changes significantly, IPAs allow facilities to update payment rates. Without timely IPAs, facilities risk underpayments. Monitoring resident status closely ensures accurate reimbursements and compliance.

8. Documentation Audits and Alignment
Internal audits catch missing diagnoses, incomplete treatment notes, or coding errors before they affect claims. Consistent documentation protects facilities from denials and keeps revenue flowing.

9. Leveraging Technology and Software
Modern EHR and coding software help identify discrepancies, flag missing data, and apply ICD-10 codes correctly. These tools reduce human error, streamline workflows, and improve billing accuracy.

10. Timely MDS Assessments
Strict deadlines for MDS submissions—including 5-day assessments and IPAs—must be met. Timely submissions prevent penalties and reimbursement delays.

11. Outsourcing for Expert Support
Because PDPM is complex, many SNFs rely on outsourcing. A professional medical billing company like 24/7 Medical Billing Services provides expert coders, compliance specialists, and PDPM optimization strategies. This reduces errors, boosts claim acceptance, and allows staff to focus on quality patient care.

FAQs
Q1. Are all states adopting Medicaid PDPM the same way?

No, Medicaid PDPM rules vary by state and must be reviewed individually.

Q2. Can poor documentation affect facility audits?

Yes. Inconsistent or missing MDS entries are common audit triggers.

Q3. What role does timing play in MDS submission?

Timely submissions ensure accurate payments and prevent penalties

Q4. How often should MDS training be refreshed?

At least twice a year to keep up with CMS changes and best practices.

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