Skilled nursing facilities work incredibly hard to deliver high-quality care, yet many still lose out on reimbursement opportunities simply because the right information is not captured at the right time.
Diagnoses are documented but not coded properly; orders are placed, but they aren’t captured; hospital records listing comorbidities that could increase PDPM accuracy are available but are overlooked.
These missed details add up quickly, and most facilities don’t realize that until after the assessment has been submitted.
Skilled nursing teams have adapted impressively to the Patient Driven Payment Model, but one of the ongoing struggles is the tendency to review PDPM information only after the MDS has been completed.
This reactive approach can cause issues that many organizations do not catch until month end. In a payment system driven by accurate diagnosis capture and precise documentation, late discovery creates lost opportunities that cannot always be recovered.
Why PDPM revenue is still missed
Even highly skilled teams face recurring issues that make reimbursement accuracy difficult. The most common challenge is incomplete diagnosis capture.
Important conditions such as pulmonary issues, neurological diagnoses, swallowing problems, infections and NTA-related comorbidities often appear in nursing notes, therapy evaluations, hospital paperwork or physician documentation but never make it onto the MDS assessment. When these items are overlooked, the facility is paid for a level of care that does not reflect the resident’s true clinical picture.
Another challenge is the delay between documentation and review. Many facilities rely on end-of-assessment checks or end-of-month audits to find missing or inconsistent items. By that point, corrections may no longer be allowed. Even when late entries are possible, they often place unnecessary pressure on teams and increase the risk of discrepancies and audits.
Cross-departmental inconsistencies are also a major liability. If therapy documents one set of conditions, nursing documents another, and the MDS reflects something different, the facility appears vulnerable during audits. CMS reviewers expect the record to tell one clear story. Any misalignment raises concerns.
Bringing PDPM oversight into daily workflow
To reduce preventable errors, facilities benefit from bringing PDPM oversight into real time. A good PDPM tool does not wait for the MDS to be closed before identifying missing information. Instead, it supports staff by monitoring resident data as it is entered.
If a diagnosis appears in documentation but has not yet been added to the active problem list or included in Section I of the assessment, a real-time tool prompts the user to review it while they are working. If a progress note mentions shortness of breath, Section J should reflect it; if a mechanically altered diet is checked off in Section K, that’s an indicator that a resident may have dysphagia. Having a system that alerts the user in real time ensures nothing from the EMR gets missed on the MDS.
This proactive approach removes guesswork from the process. Staff do not have to manually cross-reference multiple documentation sources. They do not have to rely on memory or wait for a retroactive report. Instead, opportunities and inconsistencies are identified naturally within the workflow, giving coordinators time to address them well before the assessment is submitted.
Strengthening documentation consistency and audit readiness
Documentation consistency is central to PDPM success. When clinical teams, therapy, nursing, and MDS staff all document conditions that align, the record is stronger and easier to defend. Real-time PDPM support helps achieve this alignment. By surfacing items that need attention and identifying areas where documentation may not be fully supportive, facilities can ensure that the MDS accurately reflects the resident’s condition.
This does more than improve reimbursement. It reduces confusion, supports compliance, and helps facilities feel more confident during audits. When everything is documented clearly and consistently, reviewers can easily understand the resident’s clinical situation.
Protecting revenue before it is lost
When facilities discover errors early, they preserve reimbursement that might otherwise be lost.
Many teams report significant improvements simply by capturing diagnoses and comorbidities that were already present in documentation but had not been coded. Early identification prevents financial surprises and reduces last-minute corrections that strain staff.
A more proactive future
As reimbursement models continue to evolve, real-time PDPM awareness will become increasingly important. Facilities that incorporate proactive oversight into their daily workflow are better positioned to protect revenue, reduce discrepancies, and support stronger documentation practices.
A real-time approach helps ensure that every assessment is complete, accurate, and supported. Most importantly, it allows skilled nursing teams to capture the full value of the care they provide.
Michelle Zelcer is a senior leader at Reliable Health Systems with over 20 years of experience in workflow optimization and reimbursement maximization for skilled nursing and assisted living facilities. She can be reached at michellle@reliablehealth.com.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.