Q:
What are some practice tips to determine if an IPA would increase reimbursement?
A:
The IDT should meet regularly to discuss the status of each resident utilizing their Medicare A benefits. The MDS coordinator and other key IDT members should have a thorough understanding of the components of the PDPM payment system. Helpful practice tips for determining if an IPA would be appropriate include:
Start with the “why.” Confirm that the resident has had a significant change in condition that is expected to last and is clearly supported by documentation—not just a temporary fluctuation.
Identify which PDPM component may change. Focus on Nursing, PT/OT, SLP, or NTA. If no component is likely to be adjusted as a consequence of the change in condition, an IPA will not increase reimbursement.
Closely evaluate Functional Score changes (PT/OT and Nursing).
Ask: Has the resident had a change in function that would impact the functional score?
The functional score is driven by Section GG performance and includes: Eating, oral hygiene, toileting hygiene, bed mobility (Sit to Lying; Lying to Sitting on Side of Bed), Transfers (Sit to Stand; Chair/Bed-to-Chair; Toilet Transfer), Walking (Walk 50 Feet with Two Turns; Walk 150 Feet)
Remember, GG coding translates to points:
- 05–06 = 4 points
- 04 = 3 points
- 03 = 2 points
- 02 = 1 point
- 01, 07, 09, 10, 88, or missing = 0 points
A measurable decline or improvement in functional status can impact PT/OT and Nursing, but the coding must be accurate, defensible, and supported by therapy and nursing documentation.
Evaluate new or resolved diagnoses. A new qualifying diagnosis (such as acute infection, neurologic condition, or qualifying comorbidity) may impact Nursing, SLP, or NTA—but only if it is active, treated, and documented.
Speech Component:
Has there been a change in cognition, diet, or swallowing? Have any speech related comorbidity diagnoses been added? Coding of a mechanically altered diet or signs of difficulty swallowing as outlined in K0100 can increase the Speech component case mix. Speech related comorbidities can be found at PDPM ICD 10 Mapping.
Nursing Component:
Has the resident had changes that require more licensed nursing care that would change the case mix category such as IVs, skin conditions, or acute infections. A full listing of Nursing component categories can be found in the RAI manual starting on page 6-35.
NTA Component:
There are 49 possible NTA points. Has there been additional diagnoses or services added that would increase the NTA score to change the NTA case mix grouping? A full list of NTA points can be found on page 6-30 of the RAI manual. ICD 10 codes eligible for NTA points can be located at PDPM ICD 10 Mapping.
Run a “what-if” comparison. Calculate the current PDPM rate versus the projected rate with the potential IPA to ensure there is a meaningful financial impact.
Confirm timing and sustainability. The change must be present during the IPA assessment window and expected to continue—short-lived changes rarely justify an IPA.
Balance reimbursement with compliance. IPAs should never be done solely for payment. The clinical picture must drive the decision, with documentation clearly telling the story.
When used strategically and compliantly, IPAs can support accurate reimbursement—but thoughtful review of functional status, acuity, diagnoses, and documentation is key before moving forward. The assessment reference date would be the start date for the new rate.
Next Steps!
- Access PDPM training and resources including the Proactive IPA Toolkit for training opportunities and products for PDPM success.
- Strengthen your MDS department when you register your MDS staff to join the 2026 monthly webinar coaching series–Team MDS! Insights for Quality Coding & PDPM Success
- Don’t miss MDS Orientation January 6-8, 2026 –ideal for newer MDS staff or to cross train back up team members on the MDS function
Written By:
Brandy Hayes, RN, RAC-CT, RAC -CTA
Clinical Consultant
Proactive LTC Consulting
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