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Before discussing PDPM clinical categories, it is worth understanding how PDPM works. PDPM, unlike RUG-IV, is a Case-Mix Group (CMG) reimbursement method that focuses more on clinically relevant factors and not just volume-based services. CMS notes that in July 2018, PDPM was finalized and was implemented on October 1, 2019.

In PDPM, five case-mix components are combined with the non-case-mix component, thus establishing a rate on the five-day MDS for the entire stay. SNFs are required under PDPM to classify each resident into one group for each of the five case-mix adjusted components. This is what differentiates PDPM from RUG-IV. PDPM classifies residents into separate groups for each of the case-mix adjusted components, with each component having its case-mix index and per diem rate.  

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PDPM Nursing Categories

PDPM Clinical Categories
Before discussing PDPM clinical categories, it is worth understanding how PDPM works.

When looking at PDPM nursing categories, one finds that the total number of case-mix groups has been reduced from those of RUG-IV. There are five case-mix adjusted components used in PDPM, and they are:

  1. Physical Therapy (PT)
  2. Occupational Therapy (OT)
  3. Speech-Language Pathology (SLP)
  4. Non-Therapy Ancillary (NTA) 
  5. Nursing

The Patient Classification System

Having looked at the PDPM clinical categories,  we can now look at the patient classification system: 

1. SLP Classification

Long term care facilities should understand how PDPM works, PDPM clinical categories, and how they can perfect their PDPM reimbursements.

The Speech-Language Pathologist classification in PDPM is based on the following three elements:

  • The diagnosis of the clinical category using the ICD-10-CM and ICD-10-PCS which are recorded in MDS item I8000. This diagnosis code should represent the main reason the resident requires SNF care. There are only two clinical category options for speech therapy: Acute Neurologic and Non-neurologic.
  • Determining if the resident has a swallowing disorder or if they need a mechanically altered diet.
  • Investigating whether or not the resident has a cognitive impairment. A resident can be classified as cognitively Intact, Mildly, Moderately, or Severely Impaired.

2.   NTA Classification

NTA stands for “Non-therapy Ancillary,” and it includes services outside the typical nursing costs, such as:   

  1. Organ transplants
  2. Ventilator costs
  3. Cancer treatments

3.   PT/OT Classification

The RUG-IV categories were re-classified into Case Mix Groups (CMGs) that can be broken down into two main components:.    

  1. Clinical categories: They include spinal/joint replacement surgery, orthopedic surgery, non-orthopedic surgery, non-surgical orthopedics, and medical management.
  2. Functional scoring: This is based on a resident’s eating, oral hygiene, toileting hygiene, and toilet transfer admission performance. What is the range for the nursing function score? Below is a table that clearly illustrates the function score.
pdpm nursing categories
PDPM Clinical Categories and their Functional Scores

Nursing homes and other long term care facilities may be interested in knowing how they can achieve a high PDPM functional score. This is why Experience Care’s PDPM cheat sheet may prove to be a helpful resource to nurses and nursing home administrators.

Summary of PDPM Clinical Categories

It is in the best interest of long term care facilities to understand how PDPM works, PDPM clinical categories, and how they can perfect their PDPM reimbursements. This is why Experience Care offers a comprehensive list of PDPM resources that nurses and administrators can use in their facilities. Additionally, the US Department of Health and Human Services provides a guide to PDPM, with factsheets, FAQs, and resources.

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