Understanding MDS & PDPM

MDS drives your reimbursement. PDPM determines your revenue.

The Minimum Data Set (MDS) is the comprehensive assessment required for every SNF resident. It captures clinical information, functional status, and diagnoses that directly determine your reimbursement under the Patient-Driven Payment Model (PDPM).

PDPM replaced the old RUG system in 2019, fundamentally changing how SNFs get paid. Instead of therapy minutes, payment now depends on patient characteristics-diagnoses, functional status, cognitive impairment, and clinical complexity. This means accurate MDS assessments directly impact your bottom line.

Every missed diagnosis, every incomplete assessment, every timing gap costs you money. And with CMS's focus on quality measures, MDS accuracy now affects your Five-Star rating too.

How PDPM Payment Works

PT

Physical Therapy: Based on functional score and clinical category

OT

Occupational Therapy: Based on functional score and clinical category

SLP

Speech-Language Pathology: Based on cognitive impairment and swallowing disorders

NTA

Non-Therapy Ancillary: Based on extensive conditions and medications

Nursing

Nursing Component: Based on clinical classification and ADL score

Each component is determined by MDS data. Incomplete assessments = lower payments.

The Problem

MDS coordinators are overwhelmed. Revenue is walking out the door.

3-4 hrs

Per MDS Assessment

Chart review, resident observation, family interviews, documentation-each assessment is a multi-hour process that pulls coordinators from other critical tasks.

15-20%

Missed Diagnoses

Hidden in clinical notes, lab results, and medication lists. Every missed diagnosis is money left on the table-and potentially a care planning gap.

$120+

Per Day CMI Impact

A single missed comorbidity or incorrect clinical category can reduce your daily rate by over $120. Multiply by census and length of stay-the numbers add up fast.

Why Traditional Approaches Fall Short

Manual Review

Even experienced MDS coordinators can't catch every diagnosis buried in 6 months of clinical notes. They're doing their best with overwhelming data volume.

Basic EHR Alerts

PointClickCare's built-in tools are helpful but generic. They don't learn your documentation patterns or understand your specific payer requirements.

Consulting Reviews

Quarterly audits catch errors after the fact. By then, you've already submitted and been paid incorrectly. Retrospective fixes don't recover all the revenue.

Additional Staff

Hiring more MDS coordinators doesn't solve the underlying problem-they face the same data overload. And qualified coordinators are increasingly hard to find.

Our Solution

AI that surfaces diagnoses, recommends assessments, and fits your workflow.

We built our MDS optimization platform by spending 40+ hours shadowing MDS coordinators-watching them work, understanding their challenges, learning their workflows. The result is AI that actually helps, not another tool that creates work.

Diagnosis Discovery

Our AI continuously monitors clinical documentation, lab results, medication lists, and progress notes to identify diagnoses that should appear on the MDS. It surfaces findings with direct links to supporting documentation-so coordinators can verify quickly instead of hunting through charts.

Example: Patient on Metformin with elevated A1C in labs but no diabetes diagnosis coded. AI flags for review with supporting documentation linked.

Assessment Recommendations

Beyond just finding diagnoses, our system recommends optimal assessment timing, clinical categories, and documentation improvements. Every recommendation links to the source documentation and explains the reimbursement impact.

Example: "Consider Significant Change assessment-functional status decline documented across 3 therapy notes this week. Estimated CMI impact: +$85/day."

Pre-Submission Validation

Before you transmit, our system validates each MDS against CMS requirements and internal quality standards. It flags errors, inconsistencies, and missed opportunities-catching problems before they become audit findings or revenue losses.

Example: "ADL score inconsistent with therapy documentation. Review Section GG before submission."

Quality Measure Optimization

MDS data drives your Five-Star quality measures. Our system tracks quality measure performance in real-time, identifies residents affecting your scores, and recommends documentation or care interventions to improve outcomes.

Result: CommuniCare achieved Five-Star QM Score of 60/100 and $2M in quality incentives.

Built With Your Teams

40+ hours shadowing MDS coordinators before writing code.

We didn't build this in a conference room. We sat with MDS coordinators in their facilities, watched them work through assessments, understood their documentation challenges, and learned what actually helps versus what creates more work.

That's why our system integrates seamlessly with existing workflows. No separate login. No duplicate data entry. Recommendations appear within PointClickCare where coordinators are already working.

The result: immediate adoption and $10M+ in recovered revenue.

What We Learned From Shadowing

→

Coordinators juggle 20+ assessments at once-they need prioritization, not more alerts

→

Chart review is the bottleneck-they know what to look for but can't find it fast enough

→

Every facility has different documentation patterns-one-size-fits-all tools fail

→

Trust matters-recommendations need clear source documentation to be actionable

→

Timing is everything-catching issues before submission is 10x more valuable than audit findings

Proven Results

$10M+ PDPM revenue at CommuniCare. Financial analyst calculated.

Not vendor estimates. Not projections. Actual revenue recovered, validated by an independent financial analyst, from production deployment across multiple states.

CommuniCare Health Services

One of the nation's largest post-acute care providers. Multiple states, hundreds of facilities. They needed MDS optimization that could scale without adding coordinator headcount.

PDPM Revenue Recovered $10M+ (annualized)

Quality Incentives $2M (annualized)

Five-Star QM Score 60/100

Assessment Time Savings 40-60%

Diagnosis Capture

AI identifies 15-20% more billable diagnoses that were present in documentation but not coded on assessments.

CMI Improvement

Average Case Mix Index improvement of 0.05-0.10 through better clinical classification and complete capture.

Audit Readiness

Every AI recommendation links to source documentation-creating an audit trail that protects your revenue.

EHR Integration

Works within PointClickCare. No separate system to manage.

Our MDS optimization integrates directly with PointClickCare-the EHR most SNFs already use. No separate login. No switching between systems. Recommendations appear where your coordinators are already working.

Integration includes bidirectional data flows: we pull clinical documentation and return recommendations. Updates happen in real-time, so coordinators always see current information.

For facilities using other EHRs, we have integration patterns for Epic, Gehrimed, and custom systems. The key is meeting your coordinators where they work.

Integration Capabilities

PointClickCare Native

Primary integration-production-proven across multiple states

Real-Time Data

Clinical notes, labs, medications-pulled as documented

Workflow Embedded

Recommendations appear within existing MDS workflow

HIPAA Compliant

Full compliance with BAAs, audit trails, access controls

Related Expertise

MDS optimization often combines with these domains.

See Our Work

Related Case Studies

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NeverAlone: 100K+ telehealth calls with 96% treat-in-place rate

RAF/HCC Coding

AI-powered risk adjustment serving 20K+ patients across 7 states

Documentation AI

HealthContext: 45→5 minute clinical documentation

Ready to recover your PDPM revenue?

30-minute call. We'll assess your MDS optimization opportunity and share what we've learned from $10M+ in recovered revenue.

Assess Your PDPM Opportunity

Or call: 404.654.3855

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