The shift to PDPM Medicaid isn’t just a change in payment methodology—it’s a seismic realignment of how skilled nursing and long-term care providers are evaluated and reimbursed. And many facilities are still unprepared.
If you think the transition from RUGs to PDPM is “no big deal,” you may already be falling behind.
In this article, we’ll explore what’s at stake, why so many facilities are losing $5–$15 per patient per day, and what actionable steps you can take now to ensure your community doesn’t suffer unnecessary cuts. Whether you’re in a nursing-only state or one implementing full PDPM components, there’s one truth that applies across the board:
You must make operational changes—or risk serious financial consequences.
Why PDPM Medicaid Is Different—and Why It Matters
Under the old RUGs system, therapy volume often drove reimbursement. If your therapy provider picked up enough patients, you could float your case mix index (CMI) with relatively little intervention from nursing or ancillary teams.
That safety net is gone.
PDPM Medicaid flips the script—not just on reimbursement, but also on how medical billing codes and clinical records are captured and submitted. This shift impacts everything from your MDS assessments to how your team documents care in medical records and ties it to appropriate PDPM codes.
Instead of therapy minutes, facilities must now focus on these key drivers of reimbursement:
- Section GG functional scoring
- Nursing clinical complexity
- Comorbidities, cognitive status, and diagnosis codes
- Timely, interdisciplinary documentation across care teams
Facilities that don’t adjust are already seeing sharp drops in daily reimbursement—sometimes within weeks of the change.
Are You in a Nursing-Only State? Here’s What You Need to Know
While some states are adopting all five PDPM components (PT, OT, Speech, Nursing, and NTA), most are starting with nursing-only reimbursement to simplify implementation.
The problem? That significantly limits how providers can “move the needle” on reimbursement—unless they optimize their nursing processes and documentation.
Key strategies include:
- Daily nursing documentation on clinical changes (IVs, wounds, infections, malnutrition, etc.)
- Using quarterly UDAs (Utilization Documentation Assessments) to ensure full capture during the lookback window
- Training teams to track diagnosis updates, new medications, and oxygen use
- Running clinical-only standups in addition to standard morning meetings
Facilities using EHR platforms like PCC can automate many of these data pulls—but only if staff know what to look for and when.
➡️ Need help building a PDPM-optimized nursing workflow? Gravity Consulting specializes in team training, workflow design, and documentation strategies tailored to PDPM Medicaid.
▶ Download our free State-by-State PDPM Medicaid Guide
Therapy No Longer Drives Reimbursement—But It Still Plays a Role
In states where therapy is included in PDPM Medicaid (even partially), rehab teams must rethink their approach.
Rather than focusing on minutes or frequency of therapy, providers must now:
- Capture functional decline in Section GG, especially prior to the ARD
- Ensure accurate ICD-10 coding (e.g., using “I” codes instead of “R” codes)
- Align therapy documentation with nursing and MDS assessments
Speech therapy, in particular, plays a key role in identifying swallowing difficulties, dietary modifications, and cognitive changes that impact scoring.
➡️ Gravity can audit your therapy workflows and documentation to ensure alignment with state-specific PDPM requirements and help you avoid missed reimbursement opportunities.
PDPM Coding in Medical Billing: Why It Matters More Than Ever
One of the most overlooked aspects of the transition is how it impacts PDPM coding workflows within your medical billing team. The codes selected during MDS assessments—especially the use of correct “I” versus “R” codes—can significantly influence reimbursement, particularly for speech therapy and nursing components.
If your billing team isn’t aligned with your MDS coordinators and documentation practices, it’s easy to miss reimbursement opportunities or misrepresent acuity. Providers need a documented coding strategy that links PDPM code selection to real-world charting.
➡️ Gravity can work directly with your MDS, billing, and compliance teams to ensure PDPM coding accuracy and audit readiness.
The Critical Role of Section GG—and Why Nurse Aides Hold the Key
If you remember nothing else from this article, remember this:
You can’t rely on therapy anymore. Section GG scoring by nurse aides is now one of the biggest drivers of Medicaid reimbursement.
That means:
- Nurse aides must be trained to document functional status daily
- Section GG must be treated as routine—just like vitals or care notes
- RN and LPN staff must verify and escalate any signs of decline
While this may seem like a heavy lift, the reality is: it becomes second nature once embedded into daily workflows. And the financial impact is substantial. Higher levels of documented need often result in appropriately higher reimbursement.
➡️ Gravity offers hands-on training for nurse aides, including quick-reference guides and documentation audits to improve accuracy and consistency.
Real-Time Readiness: What You Should Be Doing Right Now
Here’s a checklist of what providers should prioritize before October 1st:
✅ Determine whether your state is implementing full PDPM or nursing-only
✅ Train nurse aides and nurses on Section GG and key clinical indicators
✅ Align your medical records documentation and coding processes with PDPM reimbursement triggers
✅ Schedule targeted UDAs during the lookback window
✅ Audit current documentation practices and EHR usage
✅ Get rehab, nursing, and MDS aligned on strategy and ARD timing
✅ Download and review Gravity’s State-by-State PDPM Medicaid Guide
This isn’t the time to take a “wait and see” approach. PDPM Medicaid is here—and states are already rolling out updates monthly. In some cases, final rules are still in flux, but the effective date is fixed.
How Gravity Consulting Can Help
At Gravity, we’ve worked with providers across the country—both large systems and independent facilities—to help them:
- Navigate state-specific PDPM Medicaid transitions
- Train interdisciplinary teams on real-time documentation strategies
- Build new workflows that reflect the demands of PDPM
- Recover lost reimbursement and boost CMI through smarter data capture
We don’t just consult—we help you result.
Whether you need a full compliance overhaul, accurate PDPM coding support, help optimizing your medical records workflows, or hands-on staff training across departments, or just help making sense of your state’s latest PDPM changes, we’re ready to step in and guide you through the transition.
You can find the official CMS breakdown of PDPM here.
Final Thought:
PDPM Medicaid won’t sink every facility—but it will punish those that assume they can operate like nothing’s changed. Get ahead of the shift. Start documenting smarter. And let Gravity help you protect the margins you’ve worked so hard to earn.
