PDPM Basics
Patient-Driven Payment Model
What does PDPM stand for?
Name the 5 PDPM case-mix components.
What is PT, OT, SLP, Nursing, NTA?
What section of MDS captures primary diagnosis?
I0020B
How many points are needed for the highest NTA tier?
What is 12 +
What’s a common reason a claim may be rejected under PDPM?
What are Incomplete or invalid MDS coding
Five
How many case-mix components are there in PDPM?
Section GG
What Section of MDS impacts PT & OT scores?
This tool maps diagnoses to PDPM clinical categories.
What is the CMS Clinical Category Mapping Tool
What MDS section captures NTA items?
Section I (diagnoses), Section K, M, O
True or False: Therapy documentation still matters under PDPM.
True
PDPM
What replaced RUG-IV on Oct 1, 2019?
Speech-Language Pathology
What component uses the SLP comorbidity list?
What clinical category would a hip fracture fall into?
What is Acute Neurologic or Orthopedic Surgery
Give an example of a high-point NTA condition.
What are IV Meds, Septicemia, Ventilator use
How does Section GG impact payment rates?
Determines functional score for PT/OT
5-Day PPS Assessment
Which assessment sets the payment rate under PDPM?
The Code is 02
What score in Section GG indicates substantial/max assist?
It determines the clinical category
Why is the correct ICD-10 code in I0020B so important?
True or False: NTA is triple-weighted during days 1–3.
True
What does HIPPS code stand for?
What is Health Insurance Prospective Payment System
False
True or False: PDPM pays based on therapy minutes.
PT and OT
What two components are case-mix adjusted by day?
What happens if the diagnosis entered is “return to provider”?
The assessment is invalid for billing
What’s the max number of NTA comorbid conditions that can be counted?
50 (but only 6 points each maximum)
What must be included in the medical record to justify the PDPM score?
Clinical justification & supportive documentation from IDT