As our nursing home costs rise alarmingly and most states steady Medicaid reimbursement, our operations are “feeling the pinch.” Sad news of nursing homes closing down spans states from coast to coast with no end in sight. Now, more than ever before, nursing homes must be vigilant in their clinical care documentation to ensure they are reimbursed for every level of care and service they deliver.

One of the most significant shifts in recent years has been the introduction of Medicare’s Patient-Driven Payment Model (PDPM), which provides for per diem payments based on a resident’s functional and clinical abilities at the time of admission.

While PDPM went into effect in 2019, two still commonly undervalued components are Non-Therapy Ancillaries (NTA) and Interim Payment Assessments (IPA), which can add hundreds of dollars per day per resident more to your SNF operation’s revenues.

Identifying NTA and when to perform an IPA can be challenging. Still, operators that closely monitor and manage their NTA and IPA processes and procedures are financially stronger than those that do not. Strategies to improve your 2024 NTA and IPA opportunities vary, but a few successful suggestions are listed below.


pdpm reimbursement
Improving nursing home revenues with effective PDPM strategies.

The Basics: What is the Patient-Driven Payment Model (PDPM)?

The Patient-Driven Payment Model (PDPM) is a Medicare payment system focusing on each patient’s needs and conditions rather than the volume of therapy services provided. Implemented on October 1, 2019, PDPM aims to improve the accuracy and appropriateness of Medicare payments for skilled nursing facilities (SNFs).

Key Components of PDPM

  1. Patient-Centered Care: PDPM emphasizes individualized care, aligning payments with the patient’s clinical condition and needs.
  2. Five Case-Mix Adjusted Components: PDPM classifies patients based on five components:
    • Physical Therapy (PT)
    • Occupational Therapy (OT)
    • Speech-Language Pathology (SLP)
    • Nursing
    • Non-therapy ancillary (NTA)
  3. Variable Per Diem Adjustment: Payment rates are adjusted throughout a patient’s stay to reflect changing resource needs.
  4. Interim Payment Assessment: An IPA can be conducted to reassess a patient’s classification when there is a significant change in the patient’s clinical condition or care needs.
medicare reimbursement
Accurate patient assessments are crucial for maximizing PDPM and CMI rates.

Understanding the Case Mix Index (CMI)

The Case Mix Index (CMI) measures the complexity and resource needs of a facility’s patient population. A higher CMI indicates a more complex patient population requiring more resources, which can lead to higher reimbursement rates under PDPM.

Standard Industry Strategies to Maximize PDPM and CMI Rates

1 Accurate and Comprehensive Assessments

Conduct thorough patient assessments to ensure accurate classification under PDPM’s components. Utilize the Minimum Data Set (MDS) effectively to capture the full scope of patient needs.

2 Ongoing Staff Training

Invest in regular training for your clinical and administrative staff to stay updated on PDPM guidelines and best practices for patient assessments and documentation.

3 Utilize Technology

Implement advanced software solutions to streamline data collection, MDS submissions, patient monitoring and PDPM revenues. Tools from industry leaders like SNF Metrics are invaluable.

4 Interdisciplinary Approach

Foster collaboration among your care team, including rehabilitation specialists, nursing staff, and administrative personnel, to ensure a holistic approach to patient care and proper documentation.

5 Focus on Rehabilitation

Emphasize the importance of rehabilitation and measurable patient outcomes.

Boost Your 2024 Revenues

Revisit Your NTA and IPA Processes and Procedures

improve payment accuracy
Ensure all NTA classifications are included in pre-admission screening forms for accurate scoring.

Non-Therapy Assessment (NTA) Strategies

Considered the most transformative component of PDPM, the NTA “incentive” was provided when SNFs have residents with medically complex conditions. CMS realized that these patients require extra care and thus should be reimbursed at higher rates.

In one opportunity, the resident with a specific NTA condition can receive a triple reimbursement rate for this first 3 days of admission. In another opportunity, the NTA identifies multiple conditions and services as medically complex.

Points are awarded towards PDPM’s Comorbidity Score with the highest points receiving higher per-diem reimbursement. The challenge has been, these NTA opportunities are not always easily discoverable or well documented. Keeping staff trained and updated to identify these medically complex opportunities is a continuous process. Be diligent!

Consider reviewing these 4 opportunities with your team today:

  1. Ensure you have added all NTA classifications to your pre-admission screening forms. This will help remind staff what to look for, for NTA scoring purposes. Also, during morning meetings is your team highlighting changes in resident’s conditions that may trigger a new NTA classification (thus an IPA—more on that shortly) and thus additional points.
  2. Are coding guidelines and requirements readily available to all staff? Clinical care and reimbursement are 100% aligned–ensure your staff is aligned as well. Particularly, are you constantly educating your team on the ICD-10 NTA Comorbidity Crosswalk?
  3. Is your team diligent and asking questions about NTA coding? Are they consulting with your physicians about potential NTA opportunities? One highly noted example would be if a Body Mass Index (BMI) score is noted, does it qualify for a “morbid obesity” diagnosis?
  4. Review your ongoing diagnosis reconciliation process to ensure diagnosis accuracy. Are your teams documenting resolved diagnoses and updating any inaccurate ones?

Staying proactive and closely monitoring your teams will be rewarded with improved revenues.

Interim Payment Assessment (IPA) Strategies

pdpm implementation to support medicaid services
Regular team meetings are essential for reviewing Medicare resident care and PDPM scoring.

This optional component of PDPM allows nursing homes to reassess the resident. While not required, an IPA should be a part of every nursing home’s PDPM strategy. As changes in conditions occur that require additional care and services, PDPM allows for a change in reimbursement as well. Residents can have multiple IPAs during their stay.

Ensuring staff is educated on the IPA process and PDPM scoring should be a part of your regular and ongoing staff education and training program.

Consider reviewing these IPA strategies with your team today:

  1. Almost all nursing homes now have a routine team meeting at regular intervals to review their Medicare resident’s care and PDPM scoring. If you do not have this in place, start one with the goal ensuring all Medicare residents are properly scored and your reimbursement aligns with the great care your team provides.
  2. Revisit your PDPM staff training program with each of your facilities. Is it consistent and ongoing? Is it well-versed in the IPA triggers and procedures? Most facilities today continue to have high staff turnover rates. With high turnover comes the increased need for regular and consistent PDPM training. Your diligence will reward you with increased revenue opportunities.
  3. Some facilities note the involvement of their physicians in this IPA determination process. If you are not doing this today, consider bringing them into your IPA decision making process. If nothing else, at least make sure your physicians understand PDPM and all of its components, including the IPA and its relevancy to revenue and the overall nursing home ecosystem that includes them.
  4. While not necessarily a revenue improvement opportunity, this is important for compliance and regulatory purposes. Where your teams submitted an IPA, is it well-documented as to what was occurring and why the IPA was submitted? Review your IPA documentation processes and procedures. Don’t let someone else realize your IPA decision was not carefully documented and thus possibly not warranted. Consider during your Medicare meeting or possibly your QAPI meeting reviewing all resident IPA documentation.


Your operation can’t afford to not perform some of the checks and opportunities presented in this report. CMS launched PDPM and all of its opportunities. Two that continue to be challenging today-but provide for potential improved revenue-are the NTA and IPA. Get diligent about them. Operators that do will realize additional revenues to their operation.

If you have other NTA or IPA improvement suggestions, please let me know so that we can share them with others.

At SNF Metrics, we are committed to supporting senior care facilities through innovation and technology.  We support facilities with Apps and Analytics covering core components such as staffing, census, AR, managed care, pharmacy, risk management, referral management, clinical and billing. We also have a suite of PDPM tools available. For more information on our PDPM offering and other strategies to optimize your facility’s financial health, visit SNF Metrics.

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