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Big Changes for Long-Term Care Coding and Billing with New PDPM Rules

Posted by David Fong on Sep 12, 2019 11:00:00 AM

CountdowntoPDPMManagers of skilled nursing facilities are eagerly anticipating changes that will change the way they code, bill, collect data, and operate. A September 2019 article from McKnight’s Long-Term Care News details the long-awaited changes for long-term care reimbursements through the new Patient-Driven Payment Model (PDPM). The changes, which go into effect October 1, are revisions to the Resident Assessment Instrument (RAI), which is essentially the “rulebook” for Medicare and Medicaid reimbursements.

The article details some of the most impactful changes to the RAI manual, as well as some insights into how providers will adapt:

  • Coding changes. Important adjustments for ICD-10 case-mix codes and codes indicating “major” surgical procedures will change. Pay close attention to chapters 2 and 6 of the RAI manual which provide details on PPS assessment schedules and other policies. ICD-10 diagnoses might also trigger a “return to provider” in cases where the diagnosis is not specific.
  • Fewer assessments. There are new assessments in this manual, but the total number is lower. CMS now has two assessments for a resident’s entire stay. This move should prevent under-reimbursement issues, but will increase the importance of proper coding. An optional assessment known as the interim payment assessment (IPA) is also available.
  • Mobility and functional scoring. Functional scoring of residents (found in Section GG) are much more closely tied now to PDPM reimbursement. Mobility is also an important part of the section, and providers will need to ensure the nursing and therapy teams are documenting mobility in a coordinated way.


Impacts to Section GG

The purpose is to create a baseline of the residents’ status at both the beginning and end of their stays. Section GG is tied to payments from Medicare, as there is a requirement for submittal of at least 80 percent of certain GG data to avoid reduced annual payments. The Section GG data will also be publicly available in 2020, which will greatly affect referrals and admissions, and thereby revenues.

Recommended tips for managing Section GG include:

  • Improve collaboration by gathering data from therapists and the nursing staff as well as the family members and the actual residents (who are often overlooked).
  • The manual clearly states the clinician must be “qualified” to make the right coding decisions and is the final say for such decisions.


Aviacode’s coders keep abreast of medical coding changes, such as these, to ensure providers are paid what is allowed. Our team of experienced and certified coders accurately code more than 10 million encounters per year, helping providers avoid costly mistakes and improve their revenue integrity. Be sure to stop by the Aviacode booth #2206 at the upcoming AHIMA conference to discuss your coding needs.


Topics: Revenue Cycle Management, Medical Coding