The 3 Biggest PDPM Reimbursement Opportunities Being Missed in Skilled Nursing

At Senior Care Solutions, we often find that facilities aren’t underperforming because they lack clinical skill.

They’re underperforming because they’re not capturing what they are already doing.

PDPM is a documentation and systems model. If it’s not documented correctly,  it doesn’t count.

Here are the most common reimbursement opportunities we see being missed in both PDPM State Case Mix and Medicare PDPM.

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1.  Respiratory: The Most Under-Captured Clinical Category

Respiratory is one of the biggest missed reimbursement drivers,  especially in long-term care.

What is being missed?

✔ Chronic Lung Diagnoses + Shortness of Breath with Head of Bed Elevated

• COPD
• Asthma
• Emphysema
• Chronic bronchitis
• Chronic Respiratory failure

Many residents cannot lie flat due to breathing discomfort… but it’s never documented during the ARD window.

If:

• HOB is elevated
• Pillows are used to assist breathing
• Resident reports SOB when head flat

NOTE: That must be documented and work with provider to determine if it is tied to a respiratory diagnosis.

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✔ Respiratory Therapy (Nebulizer Treatments)

• Must have 7 consecutive days
• At least 15 minutes per day
• Minutes must include:
  
  • Set-up
  • Pre-assessment
  • Post-assessment
  • Lung sounds
  • O2 sats
  • Respiratory status response

If it isn’t clearly documented and minutes are not captured, it does not count.

Simple Tool to Implement:

From our Recipe for Reimbursement framework :

• Run monthly dx report for COPD, asthma, emphysema, chronic respiratory failure
• Create standardized quarterly respiratory assessment
• During ARD window:
  
  • Document need for HOB elevation
  • Ensure provider addresses diagnosis in progress note
• Audit nebulizer EMAR entries weekly
• Confirm 7-day, 15-minute threshold met
• Confirm there is an individualized respiratory care plan in place

2.  Wounds: Documentation That Leaves Money on the Table

Wound reimbursement is often missed due to incomplete documentation -  not lack of treatment.

Common Misses:

• Surgical wounds not clearly identified
• Treatments not defined as active treatment and not in MD or Nursing Orders
• Use of ice not documented as a surgical wound intervention
• Missing wound diagnosis and inconsistent assessment of type of wound/pressure injury

If the wound is present, treated, and active -it must be documented precisely.

PDPM is diagnosis + treatment driven. 

Simple Wound Capture Tool:

During weekly MDS review:

• Verify wound type classification
• Confirm supporting diagnosis
• Confirm treatment is documented at least daily in TAR
• Cross-check TAR with progress notes

3. Diagnosis Coding & NTA Points: The Silent Revenue Driver

This is one of the most overlooked areas in both Medicare and Case Mix.

Section I: Choosing the Correct Primary Diagnosis

The primary diagnosis must:

• Reflect reason for skilled stay ( i.e., Consider if confused- dx of encephalopathy)
• Work with provider to have supported documentation for diagnosis
• Align with therapy plan of care (if Medicare)

Incorrect primary diagnosis can significantly lower the PDPM rate.

NTA Points That Are Frequently Missed:

• Malnutrition
• Morbid obesity
• Diabetic retinopathy
• Other high-value comorbidities
• Chronic lung/respiratory conditions

If it’s not coded in Section I,  it does not generate NTA points.

4. Section K: Swallowing & IDT Communication

Under Medicare PDPM:

Swallowing disorders impact the SLP component.

Common gaps:

• SLP identifies dysphagia
• RD documents nutritional impact
• Nursing charts meal issues
• But it is never fully tied together on the MDS

There must be:

• Clear diagnosis
• Clinical support
• IDT communication between SLP and RD
• Accurate Section K coding

5. Section GG: The Foundation of Case Mix & Medicare

Section GG drives:

• Nursing Case Mix (Rates)
• PT/OT components (Rates)
• QRP compliance (Avoid dashes)

Common issues:

• Staff guessing
• Inconsistent coding between therapy and nursing
• Failure to capture late loss ADLs:
  
  • Bed mobility
  • Transfers
  • Toileting
  • Eating
• “Dash” coding impacting QRP

From our Recipe framework :

✔ Daily GG discussions during ARD window
✔ Nurse aide point-of-care documentation
✔ Weekly IDT MDS huddles
✔ Audit dependent coding (assist of 2)
✔ Clarification note before MDS closes

Goal: Accurate ADL capture. Not inflated,  accurate.

The SCS 5-Point Capture Tool

Here is a simple framework facilities can implement immediately:

Step 1: Weekly ARD Huddle

• Review all MDSs closing in next 7 days
• Review respiratory, wounds, dx, weight changes, ADLs

Step 2: Diagnosis Audit

• Run monthly dx report
• Verify NTA diagnoses supported by provider documentation
• Confirm primary diagnosis accuracy

Step 3: Respiratory Program

• Coding of respiratory diagnosis
• Quarterly respiratory assessments
• Nebulizer minute tracking
• HOB elevation documentation during ARD

Step 4: Wound Verification

• Weekly wound type and treatment cross-check
• Confirm surgical wound capture with treatment
• Ensure daily treatment documentation

Step 5: GG Integrity

• Daily discussion during ARD window
• Train nurse aides on late loss ADLs
• Audit for compliance

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Final Thought

Most facilities do not have a reimbursement problem.

They have a systems capture problem.

When documentation reflects the clinical reality already happening in your building, reimbursement aligns.