A simple form to help MDS-involved staff in calculating to 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 in mind and made by an MDS nurse who needs to determine the PDPM HIPPS fast! This form is similar to the RUG-IV table that breaks it down to determine the resident's RUG level.

This is a 15 page PDF file revised 12/04/2020.  The first 5 pages (plus 1 blank for page placement) are step-by-step questions to help determine levels or codes to be used in along with the 9-page PDPM guide of tables to calculate scores and 'converting' tables.   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 is based on many other factors (County, QRP rates, etc.) not in the equation as this form is based on the RAI manual's worksheet. 


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This is a digital download. If unable to open file, a different format will be emailed within the next business day. Sorry, no refunds because this is a digital format.

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


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