As states have transitioned to PDPM for Medicaid, many providers are discovering that the strategies that once worked under the therapy-driven RUGs model no longer deliver the same results.
For years, therapy minutes were the primary driver of case mix index (CMI) — and therefore reimbursement. But under PDPM Medicaid, therapy no longer determines rates. That shift leaves many skilled nursing and senior living providers searching for new, compliant ways to maintain or grow their CMI.
In our latest episode of Gravity Healthcare Hacks, Melissa Brown, COO of Gravity Consulting, sat down with Dr. Rehan Shah, nephrologist and co-founder of CardioRenal Vision (CRV), to explore how specialty physicians can help facilities adapt to this new environment. The discussion highlighted an important truth: the future of PDPM Medicaid success depends on accurate diagnosis, interdisciplinary collaboration, and proactive specialty involvement.
The End of Therapy-Driven PDPM Medicaid
Under the former RUGs system, therapy utilization was the primary factor influencing reimbursement. The more therapy minutes delivered, the higher the rate.
With PDPM Medicaid, however, states are basing payment on nursing and non-therapy ancillary (NTA) components — and many exclude therapy from the formula altogether.
That means facilities that continue to rely on therapy-driven CMI may experience a sharp drop in reimbursement from the transition to PDPM Medicaid.
To stay competitive, providers need a new clinical engine — one powered by accurate coding, higher-acuity diagnosis capture, and strong physician documentation.
Why Specialty Physicians Matter Under PDPM Medicaid
The specialties most closely tied to high-acuity conditions — cardiology, nephrology, and pulmonology — are now some of the most influential drivers of PDPM Medicaid performance.
According to Dr. Shah, many residents in skilled nursing facilities have undiagnosed or under-documented conditions that directly affect their CMI. Chronic kidney disease, congestive heart failure, COPD, and other cardiorenal and pulmonary conditions are often present but not coded to their full specificity.
This is where specialty physicians make a measurable difference. By embedding specialists into the care model, facilities can:
- Identify undiagnosed chronic conditions
- Improve clinical outcomes through proactive management
- Ensure documentation accuracy for ICD-10 and PDPM coding
- Strengthen reimbursement through accurate acuity capture
When providers are PDPM-trained, the impact is immediate — both clinically and financially.
Documentation and Collaboration: The Hidden Levers of CMI
As Dr. Shah shared, the key to success is not just having specialists on staff, but ensuring they understand the PDPM documentation process.
A note that reads “shortness of breath” doesn’t carry the same weight as one that specifies orthopnea due to COPD — a distinction that can double the case mix score.
Facilities that invest in ongoing physician education, regular collaboration with MDS coordinators, and quarterly documentation reviews are consistently seeing stronger PDPM alignment and fewer denials.
This ongoing communication between nursing, MDS, and specialty physicians ensures that diagnoses remain current, relevant, and supported throughout the resident’s stay — not just during the five-day PPS assessment window.
Respiratory Therapy: The Overlooked Opportunity
One of the most valuable but underutilized opportunities under PDPM Medicaid is respiratory therapy (RT).
In nursing-only states, RT carries the second-highest nursing category — yet many communities either underuse or fail to document it properly.
Dr. Shah’s team at CRV takes a co-rounding approach, pairing RT professionals with physicians to identify residents who need ongoing pulmonary evaluation or support. This model not only reduces hospital readmissions but also ensures ongoing documentation that withstands audits and denials.
Repeat testing, such as annual pulmonary function tests (PFTs), provides measurable evidence of ongoing need — strengthening both clinical care and reimbursement integrity.
PDPM Medicaid in Practice: The Texas Example
Texas is one of the most challenging PDPM Medicaid states. By consolidating the 25 CMS case-mix groups into just six, the state removed the influence of depression, restorative nursing, and Section GG on reimbursement.
That means Texas providers can only affect their rates through acuity documentation — making diagnosis specificity critical.
For example, “CHF, unspecified” no longer moves the needle. But “chronic systolic heart failure with fluid overload” or “stage 4 chronic kidney disease with proteinuria” does.
These distinctions require well-trained physicians and a structured documentation program — exactly the kind of infrastructure CardioRenal Vision helps facilities build.
The Bottom Line: A New Era of PDPM Medicaid Strategy
As PDPM Medicaid continues, the most successful providers will be those who go beyond therapy and invest in specialty-driven, documentation-focused care models.
By integrating cardiology, nephrology, pulmonology, and respiratory therapy into their clinical and operational strategies, facilities can:
- Improve outcomes and reduce hospitalizations
- Strengthen documentation and coding accuracy
- Increase CMI and reimbursement integrity
- Build resilience as states continue to refine PDPM Medicaid systems
Learn More
To hear the full discussion with Dr. Rehan Shah, listen to the latest episode of Gravity Healthcare Hacks:
🎧 Beyond Therapy: How Specialty Physicians Can Drive PDPM Medicaid Success
And if your organization is dealing with PDPM Medicaid and looking to strengthen its case mix performance, Gravity Consulting can help you put these strategies into action. Contact us at 844-899-6883