pdpm-estimatelisted

Estimate the Medicare Fee-for-Service PDPM per-diem rate and total stay revenue for a SNF admission from referral documentation (hospital packet, discharge summary, therapy notes, med list). Classifies all six PDPM components (PT, OT, SLP, Nursing, NTA, non-case-mix), applies the variable per-diem schedule, and produces a worksheet plus a length-of-stay revenue curve. Use whenever the user mentions PDPM, per-diem, case-mix groups (CMGs), HIPPS codes, Section GG function scores, NTA points, or asks anything like "what will Medicare pay for this admission," "estimate reimbursement for this referral," "is this referral worth taking financially," or "what PDPM rate would this patient generate."
magicare-ai/snf-skills · ★ 1 · Data & Documents · score 75

Install: claude install-skill magicare-ai/snf-skills

# PDPM Revenue Estimate from Referral Documentation Estimate what a Medicare Part A (Fee-for-Service) SNF stay will reimburse under the Patient-Driven Payment Model (PDPM) **before** the patient is admitted, using only the referral packet. This helps admissions and billing staff make informed acceptance decisions and spot documentation gaps early. **Why this is always an estimate:** actual PDPM classification is set by the MDS 3.0 assessment (the 5-day PPS assessment) completed *after* admission — coded diagnoses (I0020B), Section GG function scores, Section K swallowing/diet items, Section O treatments, and the rest. A pre-admission estimate built from hospital paperwork can and will differ from the final HIPPS code. Always label the output as an estimate and flag every assumption. **Scope guard:** this is Medicare FFS PDPM only. Medicare Advantage plans may pay levels, contracted rates, or their own PDPM variant — if the payer is an MA plan, say so and ask for the contract terms instead of assuming FFS rates. ## The six PDPM components Every Medicare Part A day is paid as the sum of six component rates. Five are case-mix adjusted (component base rate × case-mix index (CMI) for the patient's group, × a variable per-diem factor for PT/OT/NTA); one is flat. | Component | What drives the group | Groups | |---|---|---| | PT | PDPM clinical category (collapsed to 4) × GG function score (0–24) | TA–TP (16) | | OT | Same drivers as PT (groups can differ only via CMI) | TA–TP