Near the bottom of the Fiscal Year (FY) 2027 SNF PPS Proposed Rule released late last week is a request for information (RFI) on the Patient Driven Payment Model (PDPM) to address potential case-mix upcoding.

Industry analysts said the RFI in question is something skilled nursing providers should be well aware of, calling it “an impactful aspect of the proposed rule,” according to Brian Fuller, managing director, value-based care design and delivery, ATI Advisory.

He said this is for two reasons:

1. The Centers for Medicare and Medicaid Services (CMS) has historically utilized RFIs to narrowly target actions on issues they’ve already identified need addressing in some way (i.e., these RFIs often serve as a precursor to CMS action and policy direction).

   
   

2. Issues related to coding and Case Mix Index can significantly impact reimbursement and have done so in other payment models, such as PDGM within home health.

Digging the Details

Specifically, in the RFI, the CMS makes specific mention of Malnutrition/Risk for Malnutrition (MDS item I5600), Swallowing Disorders (MDS Section K0100), and Depression (MDS items D0160 or D0600), according to Alicia Cantinieri, managing director, clinical reimbursement and regulatory compliance, Zimmet Healthcare Services Group.

She said based on CMS’s data analysis comparing stays pre-PDPM to data from FY 2024, the agency noted an increase in reporting of malnutrition from 5 percent to 47 percent, swallowing disorders from 4 percent to 21 percent, and depression from 4 percent to 19 percent.

“This is not the first time CMS has noted an increase in coding for these items, as it has been mentioned in presentations by CMS over the past three years, so it is not a surprise that they have included an RFI to address potential changes in MDS coding ‘that do not reflect the real changes in case-mix,’” Cantinieri said.

Changes Ahead

The three items included in the proposed rule are not the only ones CMS has identified in its data analysis; it also examines the individual components.

In FY 2025 SNF PPS Proposed and Final Rules, CMS included an RFI regarding the Non-Therapy Ancillary (NTA) component of PDPM; however, thus far, there have been no proposed or final changes in the items or point values, she said.

“Based on these two RFI topics, we can expect future changes, possibly to diagnoses, case-mix index changes to the depression end-split, and NTA point values,” Cantinieri said.

“The question is always, ‘What can we do now,’” she said. “Providers can submit comments on whether they should consider other or additional data sources or methodologies. Changes are likely to be a ‘when,’ not an ‘if.’ Because CMS has provided suggestions on specific focus areas, we can expect increased scrutiny in audits as well. As audit enforcement has increased, MDS coding accuracy and supporting documentation are paramount to success.”

The SNF Final Payment Rule can be viewed on the Federal Register at: https://www.federalregister.gov/d/2026-06674.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.