What Every Nursing Home Administrator Needs to Know About PDPM, MDS Accuracy, and iQIES Reports
Insights from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, IPCO, QCP, ICC, Director of Reimbursement and Education, Pathway Health
If you’re a Nursing Home Administrator (NHA), you already know that the Patient-Driven Payment Model (PDPM) isn’t just a reimbursement model—it’s a whole new way of thinking about care, documentation, and financial sustainability. But here’s the kicker: even small oversights in your Minimum Data Set (MDS) assessments can cost your facility thousands of dollars per resident.
So how do you stay on top of it all? That’s where iQIES comes in—and where your leadership really shines.
First, a Quick Refresher: What is PDPM?
PDPM is Medicare’s payment model for skilled nursing facilities. It replaces the old RUG-IV system and focuses on resident characteristics rather than therapy minutes. It breaks reimbursement into five components:
- Physical Therapy (PT)
- Occupational Therapy (OT)
- Speech-Language Pathology (SLP)
- Nursing
- Non-Therapy Ancillary (NTA)
Each of these is calculated based on MDS data. That means accurate, timely, and complete MDS coding is everything.
Common MDS Mistakes That Hurt Reimbursement
Let’s talk about where things often go wrong:
- Swallowing disorders not documented → Lower SLP score
- Oxygen therapy missed in Section O → Lower Nursing and NTA scores
- Shortness of breath while lying flat not captured → Missed Nursing points
- Active diagnoses not coded → Lower NTA classification
- Functional status (Section GG) inconsistencies → Reduced PT/OT payments
These aren’t just clerical errors—they’re lost revenue.
Enter iQIES: Your Navigation Tool
iQIES (Internet Quality Improvement and Evaluation System) is CMS’s cloud-based platform that houses all your MDS submissions, reports, and quality data. Think of it as your mission control for compliance and reimbursement.
Key iQIES Reports Every NHA Should Review
Here’s what to keep an eye on:
1. MDS Submission Status Report
- Why it matters: Ensures all assessments are submitted and accepted.
- Pro tip: Set a weekly reminder to check for rejections or late submissions.
2. MDS Error Summary Report
- Why it matters: Flags missing or inconsistent data that could affect PDPM scoring.
- Pro tip: Use this to coach your MDS team—turn errors into learning moments.
3. PDPM HIPPS Code Report
- Why it matters: Shows the payment codes generated from MDS data.
- Pro tip: Compare these codes to your expected case mix. If they’re off, dig into the MDS.
4. Resident-Level Validation Report
- Why it matters: Lets you drill down into individual assessments.
- Pro tip: Use this to spot trends—are certain diagnoses or symptoms consistently missed?
5. Quality Measure Reports
- Why it matters: While not directly tied to PDPM, they reflect documentation quality and care outcomes.
- Pro tip: Align your quality goals with reimbursement goals—it’s all connected.
Helpful Hints for NHAs
Here’s how to stay ahead of the game:
- Create a PDPM Dashboard: Track key metrics like IPA usage, average case mix, and error rates.
- Host Monthly MDS Huddles: Bring together nursing, therapy, dietary, and MDS staff to review trends and share insights.
- Audit 5 Charts a Month: Randomly review MDS assessments for accuracy—especially in Sections I, K, GG, and O.
- Celebrate Wins: When your team catches a missed diagnosis or improves documentation, recognize it. It builds a culture of excellence.
Final Thoughts
PDPM isn’t just about payment—it’s about precision. As an NHA, your role is to lead the charge in aligning clinical care, documentation, and financial performance. With the right use of iQIES reports, a sharp eye on MDS accuracy, and a proactive team, you can turn PDPM into a powerful tool for both quality and sustainability.
Pathway Health Resources
Access helpful tools and resources to help you and your team navigate any reimbursement questions you may have.
- Reimbursement Resources: From training modules to complimentary checklists and tools, we have numerous resources to help your facility succeed. Learn more.
- MDS Baseline Assessment: Receive the support of one of our MDS expert consultants to obtain support with identifying training needs, standardizing documentation practices, strengthening IDT communication and more. For more information, connect with our team here.
Register for a Complimentary Webinar on R.O.I.
Register for an upcoming complimentary CE session on 7/8/2025, “What Every Leader Needs to Know About R.O.I. (Reimbursement Optimization Improvement)”.
This session will provide leaders with keen insight into missed reimbursement opportunities, what leaders need to know, and resources leaders can use to stay on top of all of the changes impacting their financial outcomes.