PDPM Medicaid Uncovered: What Facilities Miss (and How to Get Ahead)

In this second half of our deep dive, Melissa Brown, COO of Gravity Consulting, continues her conversation with Melissa Keiter on the critical challenges—and opportunities—of PDPM Medicaid.

This episode unpacks real-world strategies for facilities navigating the transition, from documentation pitfalls and audit risks to proactive coordination across nursing, MDS, therapy, and ancillary partners. You’ll hear insights on:

• Why supportive documentation is more important than ever
• How respiratory therapy, wound care, and psychological services can strengthen your PDPM scores
• The role of coordination between MDS, clinicians, and outside specialists
• Why a proactive, team-based mindset is essential to avoid leaving dollars—and care opportunities—on the table

Whether your state has already transitioned or is still under a rate freeze, this episode will help you prepare your staff, adjust your systems, and avoid the financial and operational risks of falling behind the curve.

Transcript

Gravity Health Hacks — Episode 59 (Part 2)

Will PDPM Medicaid Sink Your Facility? What You Need to Know Before You Fall Behind the Curve
Host: Melissa Brown, COO, Gravity Consulting
Guest: Melissa Keiter

Intro
Melissa Brown (Host):
You’re listening to Gravity Health Hacks with your host, Melissa Brown—Chief Operating Officer at Gravity Consulting and self-professed healthcare nerd. Each month, we share expertise and tips to help keep your feet firmly on the ground in the world of healthcare.

Melissa Brown:
Hello, everyone—welcome back to the Gravity podcast. I’m excited to share the second episode on PDPM Medicaid: Will it sink your community? There was so much to cover that we split it into two parts. Let’s jump back in with Melissa Keiter for tips, strategies, and ideas to help you successfully navigate your state’s transition to PDPM Medicaid.

I think these UDAs are more important than people realize. Many PDPM-Medicaid items on the MDS have short look-back periods—it’s not two or three years. Even when it isn’t short, take “shortness of breath while lying flat” with COPD: if it was last documented a year ago and there’s been no recent re-documentation, it’s easy for a Medicaid auditor to pull that back and for a state surveyor to cite you. You need relevant, recent proof that the condition persists and justifies payment. Thoughts, Melissa?

Melissa Keiter (Guest):
With the switch, states vary in supportive documentation requirements. Educate yourself on your state’s rules. Some states won’t accept only a checkbox “yes” on the TAR (Treatment Administration Record) for “shortness of breath while lying flat.” They want more detailed documentation. Learn the new supportive documentation guidelines under PDPM for case-mix; some states accept yes/no, others do not. Know precisely what your state requires.

Melissa Brown:
Great point. Let’s pivot to NTA—though nursing and NTA often overlap, and many strategies help both. One big opportunity: respiratory therapy for long-term care residents. Establish a protocol:

• Obtain baseline respiratory function testing to support need.
• Repeat at clinically appropriate intervals to show ongoing benefit.
• Have an RT on campus at least a couple of days per week for evaluations and quarterly assessments (at minimum).
• Think beyond nebulizers—consider incentive spirometry or other RT treatments that may be captured.

Know your state’s rules, but a good RT partner will also know how to document appropriately. We can’t put everyone on RT or rely on floor nurses to generate 15 minutes of face-to-face for each resident. But with a clinical protocol and trained RTs, you get the documentation you need. Getting that “shortness of breath while lying flat” from an RT evaluation or quarterly assessment carries more weight than a daily TAR checkbox. Any other RT strategies?

Melissa Keiter:
If you have an RT, MDS should share assessment schedules just like they do with rehab—give notice a few weeks in advance. That way, if someone is (or will be) on caseload, the RT can see the resident within the seven-day look-back window.

Melissa Brown:
Exactly. Many nursing strategies apply to NTA as well. Provide ongoing—not one-and-done—education for RNs, LPNs, and your IDT. Keep the “top 50” conditions and extensive services front-and-center for NTA capture.

Also, consider bringing partners onto campus: wound physicians, cardiology, nephrology, pulmonology, and physiatry. But choose PDPM-trained clinicians who understand how to support documentation for reimbursement. They might come monthly or quarterly per protocol and produce strong documentation that bolsters nursing and NTA scores.

As under the old system, timing matters. If therapy picked a resident up a week after the ARD, it didn’t help unless you did another assessment. Same thinking here: ensure MDS and the consulting clinician know the ARD so their monthly/quarterly note lands squarely inside the seven-day look-back. That reduces scrutiny and strengthens support.

Melissa Keiter:
Another strategy: psychological services. In audits we’ve done at Gravity, we’ve seen PHQ-2/9 documentation where no one was captured for signs/symptoms of depression—every MDS scored “0.” That’s impossible.

Have MDS coordinate with psychological services just like with rehab—share the schedule. Let the psychiatrist/psychologist conduct the PHQ-2 (and expand to PHQ-9 as needed). They know the resident, have time to interview properly, and understand the resident’s history (depression, anxiety, PTSD). When they conduct the screening, we see appropriate, non-zero scores (often 8–10 when warranted). That’s a huge strategy.

Melissa Brown:
Agreed. As a gut check: with PHQ-2 to PHQ-9, typical capture rates we’re seeing now are around 10–12% across short stay and long-term care. If you’re well below that—especially near zero—the assessment is probably not being done correctly.

We’ve seen buildings where no one scored above zero across multiple MDS audits. That’s not reality, and it means two things: you’re leaving money on the table, and you’re missing residents who need help because the screening isn’t being done right.

A practical fix: send someone who truly knows the PHQ-2/9 to observe the social worker conducting 5–10 screenings. You’ll quickly spot issues: leading questions, cuing residents, or failing to set the environment. If you don’t establish rapport, very few residents will disclose sensitive information. How you do the assessment matters.

Melissa Keiter:
Exactly. Many interviews feel rushed—“I need to ask you these questions”—and residents don’t feel comfortable. Psychological services know how to set the tone, spend 20–25 minutes, and they’re likely seeing the resident monthly anyway. Coordinate so their visit falls within the assessment window.

Melissa Brown:
You’re hearing a theme: be proactive and surround yourself with the right partners. Don’t wait. Even if your Medicaid payment looks similar moving from RUGs to PDPM, why leave dollars on the table? These same strategies help your skilled side, too. Look for PDPM-trained partners and coordinate, coordinate, coordinate.

The title “MDS Coordinator” has never been more accurate. Your #1 job is coordinating services, timing, and ARD adjustments based on clinical indicators—most of which now sit outside of therapy.

Melissa Keiter:
As an MDS coordinator myself: you cannot schedule every MDS exactly every 92 days and call it done. If you do, your facility is likely to sink under PDPM case-mix. Be proactive, not reactive. Educate, train, re-educate, and coordinate with partners.

The MDS role has never been more significant. Therapy doesn’t “carry” you anymore. You need social work, dietitians, PT/OT/SLP (for what’s still relevant), outside consultants, nurses, nurse aides, and frontline staff. Otherwise your CMI can nosedive—and then you’ll be asking, “How do we dig out?” Train your IDT, hold morning meetings, talk through residents, and time your MDS to capture what’s present.

Pull 24-hour reports. See what you can capture. Query physicians when you see undocumented diagnoses. It’s a mindset shift. We used to rely on therapy; that’s no longer the case. Put strategies in place. Lead. Be proactive.

Melissa Brown:
And if you’re an administrator or executive hearing “It’s just nursing—business as usual,” that’s not accurate. Under RUGs 3/4, therapy trumped nursing. Now therapy is out of the driver’s seat for PDPM Medicaid; nursing/IDT clinical indicators drive payment (with Section GG as the big change area from RUGs). If your MDS coordinator sees this as status quo, they need additional training and support.

Let’s talk about state transitions. We knew PDPM Medicaid was coming in 2019, but the pandemic understandably delayed things. Still, many states seemed unprepared and simply froze rates—some for a year, 18 months, even two years. That’s unfair to providers, removes your ability to move up, and creates false security.

From what we’ve seen, it can take a year or more of consistent work—with consulting support and a strong MDS coordinator—to move from a RUGs-oriented building to a PDPM-Medicaid building. If you’re in a rate-freeze state, don’t wait. You may not know how your state will implement PDPM, and in some places the MDSs you submitted six months earlier end up influencing payment when they switch. If you start late, you can’t catch up—and you may see a significant drop for a quarter or two.

Start now. Be accurate. Get your systems in place so you’re not on the wrong side of the transition. It typically takes at least a year to streamline the team, clarify roles, and tighten documentation.

Melissa Keiter:
The longer you wait, the harder it is to adopt the PDPM mindset. We’ve been RUGs-focused forever—it felt straightforward: communicate with therapy, get minutes, the CMI goes up. Now it’s a team mindset—social work, dietary, nursing, RT, psych, physicians, MDS, and more. Not just MDS + rehab. Again: be proactive, not reactive.

Melissa Brown:
Don’t wait. Most of what we discussed today costs nothing—other than respiratory therapy—because it’s about systems, training, and coordinating people you already have, or partnering with ancillary clinicians who bill Medicare directly.

We’ve built a comprehensive resource on the Gravity website with these strategies and more—whether your state is nursing-only, includes NTA, or involves therapy in its PDPM Medicaid model. It also lists every state and what they’re doing now; we’ll keep it updated over the next year as things solidify.

If you have questions, find me (Melissa Brown) or Melissa Keiter on LinkedIn or via the Gravity website. And a big thank-you—we just crossed 5,000 downloads. We hope we’re helping you and making a difference.

Don’t forget to subscribe. And remember: it’s not just what you know, but how you apply it that makes all the difference. See you next time.