Harmony Healthcare Blog

[ICYMI] Top 10 Things You Need to Know About PDPM Transition

Posted by Kris Mastrangelo on Thu, Oct 10, 2019

Edited by Kris Mastrangelo

Kris Quote Blog 9.10.19


Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency

It's October and the phone is off the hook with PDPM questions.  This blog started as a HIPPS informational narrative but morphed relatively quickly into a twitter on steroids PDPM transition blitz of information.  

In true Harmony Healthcare International (HHI) fashion, here are the Top 10 things you need to know about PDPM Transition:

  1. PDPM Begins October 1, 2019 with no overlap from RUGS-IV.
  2. HIPPS (Health Insurance Prospective Payment System) Codes will be different October 1st.

    The RUGS-IV HIPPS Codes are different than the RUGS-IV HIPPS Codes.  If the claim displays the wrong HIPPS, payment will be jeopardized. HIPPS codes cannot cross months.

    To gain a better understanding of HIPPS, see number 10 below.
  3. Complete IPA (Interim Payment Assessments) with an ARD no later than October 7, 2019, for all current SNF Medicare Part A patients.

    The below table shows the ARDs in relation to the admission date.

  4. Complete PDPM 5-Day Assessments for newly admitted (October 1, 2019 or later) SNF Medicare Part A patients.

  5. Variable Per Diem will apply for those patients already on Medicare Part A prior to October 1st.
  6. Any “transitional IPAs” with an ARD after October 7, 2019, will be considered late and the relevant penalty for late assessments would apply.
  7. The default payment HIPPS for PDPM will be ZZZZZ unlike the current AAA score used currently.
  8. CMS is calling PDPM PPS.
  9. Harmony Healthcare International (HHI) created a RUGS-IV Nursing component crosswalk. Download below. 

    Download  Consolidated Billing: 5 Major Categories Skilled Nursing Facility
  10. HIPPS Detail for RUGS-IV and PDPM (Health Insurance Prospective Payment System)

    Based on responses on the MDS, patients are classified into payment groups, which are billed using a 5-character Health Insurance Prospective Payment System (HIPPS) Code.

    1. The current RUG-IV HIPPS Code follows a prescribed algorithm.

      Character 1-3:  RUG Code
      Character 4-5:  Assessment Indicator
      • 10 – 5 day
      • 20 – 14 day
      • 30 – 30 day
      • 40 – 60 day
      • 50 – 90 day
      • 0D – COT Standalone
      • 04 – EOT
      • 07 – SOT

        Example:  RUC10 means Rehabilitation Ultra High 5-Day Assessment
    2. The October 1, 2019 PDPM HIPPS Code follows a prescribed algorithm. In order to accommodate the new payment groups, the PDPM HIPPS algorithm is revised as follows:

      Character 1:  Physical Therapy/Occupational Therapy Payment Group

      Character 2:  Speech Therapy Payment Group

      Character 3:  Nursing Payment Group

      Character 4:  NTA Payment Group

      Character 5:  Assessment Indicator (this shows up on the MDS).

    3. In order to see the transformation, below are the HIPPS Tables

Table 1: 

Character 1: Physical Therapy/Occupational Therapy Payment Group,

Character 2: Speech Therapy Payment Group and

Character 4: NTA Payment Group below

Table 2:

Character 3:  Nursing Payment Group

Table 3: 

Character 5: Assessment Indicators


  • Physical Therapy/Occupational Therapy Payment Group: TN
  • Speech Therapy Payment Group: SH
  • Nursing Payment Group: CBC2
  • NTA Payment Group: NC
  • Assessment Type: 5-Day PPS Assessment

    Answer:  HIPPS Code: NHNC1

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

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