A simple form to help MDS-involved staff calculate and determine each of the PDPM case-mix components: PT, OT, SLP, Nursing and NTA. This worksheet was made because other forms that are out there had extra information not needed! This guide is simplified to be used by a busy MDS nurse or MDS-involved clinician.  The form was made by an MDS nurse for those who need to figure out the PDPM HIPPS fast and also see the other conditions that may impact the payment!  (This form is similar to the RUG-IV table that breaks down patient conditions to determine the resident's RUG level.)

This is a 15 page PDF file revised 12/04/2020.  A portion of the file has 5 pages of worksheets (plus 1 blank for page placement) that lists the step-by-step questions to calculate levels or codes.  The other portion is a 9-page PDPM guide of 'conversion' tables to calculate scores, levels, groups and codes.   The ICD 10 mapping (free from CMS.gov and free for download in the Free Forms & Resources page) provided by CMS is to be used in conjunction with this guide. 


Reminder:  The sample rate is based on the LA County, CA rate.  Your patient's actual daily reimbursement will vary due to other factors (County, QRP rates, etc.) not in this form as this form is based on the worksheets in Chapter 6 of the RAI manual which does not include those other factors.  


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PDPM Worksheet Guide: A form to calculate & determine the 5 PDPM components


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