Are you Ready for PDPM?

Lisa Volk and Nancy Leveille in Clinical & Quality

A new payment system known as the Patient Driven Payment Model (PDPM) takes effect October 1 that will transform the way skilled nursing facilities are reimbursed for Medicare Part A stays. 

Some of the changes coming October 1 include:

  • The PDPM system will rely on more than 180 MDS item fields and completely transforms the existing system Medicare Part A payment system for skilled nursing facilities. Staff roles and facility processes must be substantially modified to operate effectively under PDPM, including ICD-10 coding which will directly tie to reimbursement.
  • Simply accepting the hospital’s ICD-10 code or using the ICD-10 code that seem most appropriate won’t work under PDPM. Assuming the admitting physician has the correct diagnosis and code won’t work either. MDS Coordinators and billing staff must be masters at ICD-10 coding and how it maps to PDPM and play an active role in admission process.
  • As a condition of coverage, physicians must certify on admission and then recertify by day 14 and every 30 days thereafter that skilled care is needed. Physicians and MDS Coordinators must be able to understand and effectively communicate about arriving at the reason for SNF care and defining the clinical basis for admission using appropriate ICD-10 codes that map to PDPM.
  • Primary diagnosis tied to accurate ICD-10 coding will matter more than ever under PDPM. CMS will have a much clearer way to monitor whether SNF care is really needed. Accurate ICD-10 coding will minimize the risk of payment delays and denials.
  • SNFs that are not well versed in PDPM and ICD-10 coding are at a much higher risk of seeing their revenue negatively impacted and are at a substantial increased risk for potential audit and recovery. 

If you did not attend our in-person PDPM Academy training earlier this year, I urge you to register now for AHCA’s Virtual PDPM Training. Included with the virtual training is access to all materials on AHCA’s PDPM Academy. The PDPM Academy is where updates, tools, webinars and other supporting materials are housed. AHCA SNF members who attend the Virtual PDPM Training will also be able to join in free monthly PDPM Academy webinars hosted by AHCA.

This training is available to SNF provider members only. The cost for the training – whether first time or repeated - is $350. The training has been approved for 8 NAB CE credits.

Virtual ICD-10 Coding training is also available through AHCA and is equally important to PDPM success and bulk purchases are available. There are two online trainings offered, including:

  • AHCA/AHIMA ICD-10 Training for PDPM – Coder is an in-depth course designed for SNF billing staff, MDS staff, Nursing and Therapy staff, and Admissions and Discharge staff. The course contains seven modules and comes with 16 CNEs for nurses and 16 AHIMA CEs upon successful completion. The cost is $499 for AHCA members and $599 for non-members. AHCA/AHIMA ICD-10 Training for PDPM – Coder: 
  • AHCA/AHIMA ICD-10 Training for PDPM – Non-Coder is a four-hour course developed for individuals who need to lead a successful PDPM transition and is intended for Administrators, DONs, and other management staff. The course for non-coders comes with 4 CNEs for nurses, 4 AHHIMA CEs or 4.5 NAB approved CEs upon successful completion. The cost is $199 for AHCA members and $249 for non-members. AHCA/AHIMA ICD-10 Training for PDPM – Non-Coder:

Members will need to login with their AHCA/NCAL usernames and passwords to register for any of these courses. For assistance obtaining AHCA/NCAL usernames and passwords, please e-mail educate@ahca.orgwith your name and facility contact information. 

PDPM will be here soon. I encourage all members who have not done so to sign up for these courses to be ready for this new Part A payment model. Please contact me if you have any questions.


Lisa Volk, RN, B.P.S., LNHA
Director, Clinical & Quality Services
518-462-4800 x15

Nancy Leveille, RN, MS
Executive Director
518-462-4800 x20