SNF Medicare Part A Billing (PDPM)
PDPM-driven Part A billing built around your 5-day MDS. Five-component HIPPS coding for PT, OT, SLP, Nursing, and NTA. IPA and IPO trigger monitoring. UB-04 and 837i institutional claims. Variable per-diem tracking through day 100. We work inside PointClickCare and MatrixCare alongside your MDS coordinator.
0:55
0:48Missed IPA triggers. Wrong HIPPS code. Per-diem revenue lost.
PDPM moved SNF Part A from minutes-driven RUG-IV to clinical-characteristic case-mix in October 2019 under 42 CFR 483. The shift gave facilities five separate payment buckets to manage on every claim. Most billing teams still treat PDPM like RUG-IV, and that quiet gap leaks revenue every day a resident is in the building.
NTA comorbidities not captured
The NTA (Non-Therapy Ancillary) component pays up to 3x for the first 3 days then a flat per-diem after. One missed ICD-10 diagnosis on the 5-day MDS can drop NTA from category 4 to 2. That is often 30 to 70 dollars per resident day for the rest of the stay.
IPA triggers missed mid-stay
Interim Payment Assessments (IPA) are optional under PDPM but recommended when a clinical change shifts a case-mix component. Without active IPA monitoring, the original 5-day HIPPS stays locked even when therapy minutes drop or nursing acuity rises. The facility either overbills or underbills.
Variable per-diem not tracked
PT and OT components ramp down 2 percent every 7 days starting day 21 (variable per-diem). NTA pays 3x for days 1 to 3. UB-04 line items must reflect the right per-diem for each date range. Manual calculation errors are common and add up across the 100-day benefit.
Tell us about your agency.
Send us your situation and our team will scope the right setup, usually within one business day. No obligation.
What is SNF Medicare Part A billing under PDPM ?
SNF Medicare Part A billing under PDPM is the end-to-end process of converting a 5-day MDS assessment into a HIPPS code, attaching it to a UB-04 or 837i institutional claim, applying the variable per-diem schedule across the resident's covered days, and reconciling payment against the case-mix components. It is governed by CMS PDPM rules at 42 CFR 483 and tied to the SNF prospective payment system.
What your PDPM billing team actually handles, day to day
Eight production queues that map directly to the PDPM lifecycle. From 5-day MDS to final 835 remit, your billing pod covers every step.
5-day MDS to HIPPS conversion
Reads MDS sections GG, I, K, O, and the new BIMS items. Calculates the five case-mix components and the final HIPPS code that drives Part A per-diem.
UB-04 and 837i submission
Builds the institutional claim with revenue codes 0022, 0185, 0552. Validates HIPPS placement in form locator 44. Submits through clearinghouse with edits resolved.
IPA trigger monitoring
Watches for clinical changes that justify an Interim Payment Assessment: therapy minute shifts, nursing acuity change, NTA comorbidity onset, swing-bed transitions.
Variable per-diem tracking
Calculates the PT and OT 2 percent step-down every 7 days starting day 21. Applies NTA 3x premium for days 1 to 3. Splits UB-04 line items by date range.
NTA comorbidity capture
Cross-checks physician orders, hospital discharge summaries, and Section I diagnoses against the 50-condition NTA scoring list. Flags items missed on the 5-day MDS.
100-day benefit window
Tracks Part A days used against the 100-day SNF benefit per spell of illness. Flags day 20 and day 100 cliffs. Coordinates with admissions for benefit period reset rules.
MAC rejections and rebills
Reads 277CA acknowledgments. Resolves HIPPS mismatches, occurrence code errors, and value code 80 issues. Re-bills within timely filing.
835 remit reconciliation
Posts ERA against the SNF PPS rate. Splits MSP and secondary balances. Flags underpayments against the published per-diem and case-mix index.
PDPM-tested billers, not generic medical coders
Most outsourcing companies will assign a general medical coder to your SNF Part A queue and call them a "PDPM biller." We do not. Every Staffingly biller on a PDPM account passes a pre-placement assessment on the 5-day MDS, the five case-mix components, the variable per-diem schedule, and at least one major platform from PointClickCare, MatrixCare, or American HealthTech.
PDPM-tested pre-placement
Every biller passes a written assessment on MDS sections GG, I, K, and O, plus the HIPPS code structure, IPA triggers, and the 100-day benefit period before placement on a live SNF account.
Stacked compliance posture
HIPAA + SOC 2 Type II + ISO 27001 + HITRUST. Plus alignment with 42 CFR 483 PDPM rules and 45 CFR 164.514 de-identification. Ask your current vendor for proof of all four.
2-Week Risk-Free Pilot
Industry standard offers no trial. We give you 14 days of live PDPM claim work at the same rate. Cancel before day 14, owe nothing. No annual contracts after.
Staffingly vs DIY in-house vs generic offshore vs onshore BPO
The real cost math for a single full-time PDPM biller or coder role at a mid-size SNF.
From "let's talk" to live in 1 to 2 weeks
Six steps. Each one is documented. Nothing is mysterious.
Discovery call (15 min)
We review your current PDPM HIPPS distribution, recent IPA frequency, and your top 3 case-mix gaps. No prep needed from you.
BAA + platform access
Business associate agreement signed. Role-based access provisioned in PointClickCare or MatrixCare SNF Financial Management module.
MDS shadow (2 to 3 days)
Your PDPM pod shadows your MDS coordinator and business office. 5-day workflow captured. IPA decision tree locked. Escalation routes documented.
Parallel pilot starts
Week 2 to 3. Your pod runs alongside your team. Daily 15-minute sync. You see every UB-04 submitted, every HIPPS code validated, every IPA recommendation.
Decision point (end of week 2)
Pilot results reviewed. Go or no-go. No penalty if you cancel. Most SNFs keep going past day 14.
Full handoff, cadence locked
Clean-claim rate, IPA trigger rate, NTA capture rate, and DSO KPIs in your inbox. Weekly review with your account lead. Monthly QA audit.
How your PDPM billing pod's day actually looks
A real shift, hour by hour. Times shown in your local time. Coverage rotates so your SNF billing desk is never dark during business hours.
How Staffingly works, in practice
Inside the workA trained Staffingly specialist works inside your existing platform, with clear escalation back to your team.
One Flat Weekly Rate. No Surprises.
Dedicated senior care schedulers at a fixed weekly cost. Per scheduler FTE, per week. No contracts, no minimums, no hidden fees.
Want to compare against an in-house hire? Use the savings calculator.
Frequently asked questions
What are the five PDPM case-mix components, and how do they affect the per-diem?
PDPM uses five separate case-mix components under 42 CFR 483: PT, OT, SLP, Nursing, and NTA. Each has its own case-mix index and base rate. The HIPPS code captures all five. PT and OT use Section GG functional scores. SLP uses cognitive status, swallowing, and mechanical altered diet. Nursing uses 25 categories tied to ADL and special care. NTA uses a 50-condition comorbidity list. Together they drive the Part A per-diem.
When should an IPA be triggered?
IPA is optional under PDPM but recommended when a clinical change shifts a case-mix component: nursing acuity change, therapy regimen modification, NTA comorbidity onset, or significant functional decline. The IPA ARD must be set within 14 days of the change.
How is the Interim Payment Assessment timed and submitted?
The IPA ARD can be set on any day during the Part A stay after the 5-day. Once submitted to iQIES, the new HIPPS applies prospectively from the ARD forward. Original 5-day HIPPS still applies before the IPA ARD. UB-04 line items are split by date range.
How is PDPM different from RUG-IV?
RUG-IV was minutes-driven. PDPM shifted to clinical characteristics: ICD-10 diagnoses, Section GG functional scores, NTA comorbidities. PDPM introduced variable per-diem (PT and OT step-down after day 20, NTA 3x for days 1 to 3) and made IPA optional. Took effect October 1, 2019 under 42 CFR 483.
What is the difference between MS-DRG and HIPPS coding?
MS-DRG is the inpatient hospital Part A payment classification under 42 CFR 412. HIPPS is the SNF Part A payment code under 42 CFR 483. The 5-day MDS generates the HIPPS code that drives SNF per-diem for the post-acute stay.
How is PHI and HIPAA handled for remote PDPM billing?
Full HIPAA-aware workflow with signed BAA, role-based EMR access, and audit logging under 45 CFR 164.514 de-identification rules where applicable. Billers work from biometric-secured facilities under HIPAA, SOC 2 Type II, HITRUST, and ISO 27001 aligned controls.
How does pricing work for PDPM billers across multiple SNFs?
Per PDPM biller FTE, per week. No setup fees. $399 Standard, $349 Volume (3 or more), $299 Enterprise (10 or more). Add or remove billers by the week. No annual contracts. Multi-state SNF groups can pool billers across facilities.
What is included in the 2-Week Risk-Free Pilot for PDPM billing?
Two weeks of live PDPM billing work in parallel with your business office. Full reporting on clean-claim rate, HIPPS validation, IPA recommendations, and NTA captures. No setup fee. No penalty if you cancel before day 14.
President and CEO, Staffingly, Inc. 25+ years in IT consulting and healthcare BPO operations. One of the earliest US operators to set up an RPO/BPO delivery network in India. Leads AI-driven home care workflows that help agencies, home health providers, and multi-branch operators cut admin cost without compromising care.
