PDPM Casemix Audit- Nursing Component

Your PDPM nursing component is one of the most complex — and most consequential — pieces of your reimbursement puzzle. A single miscoded nursing category, a missed depression end-split, an unsupported Section GG score, or a PHQ pathway error can shift a resident's HIPPS code, reduce your per diem rate, and create audit vulnerability that follows your facility for years. The InsightMDS PDPM / Casemix Audit — Nursing Component by Insight MDS & Therapy Solutions gives your team a powerful, structured internal audit tool to catch those issues before they become denials, recoupments, or survey findings.

Built from the CMS RAI Manual v1.20.1 (effective October 1, 2025) and designed for real-world SNF use, this comprehensive audit tool is available in two formats included with your purchase — a fully functional Excel Workbook for digital auditing with built-in compliance calculations and a roll-up dashboard, and a clean Printable Web Browser version for facilities that prefer a paper-based audit workflow or need printed copies for audit files, MAC requests, or internal review meetings.

Built on Real-World Expertise You Can Trust:
This audit tool was developed by experienced MDS professionals with hands-on, multi-state Casemix audit experience — and its audit criteria and compliance standards are grounded in guidance and educational content from Myers and Stauffer, one of the nation's leading healthcare consulting and audit firms. The audit questions, look-back logic, and documentation requirements built into this tool reflect not just what the RAI Manual says — but what auditors are actually looking for when they review your records. This isn't a theoretical compliance checklist. It's a practical, audit-tested framework built by people who have sat across the table from auditors, reviewed real charts, and know exactly where SNF nursing documentation breaks down under scrutiny.

Two formats. One powerful audit.

🖥️ Excel Workbook — A structured digital audit workbook with individual patient tabs for up to ten residents, automatic compliance rate calculations, a facility-wide roll-up dashboard, and built-in HIPPS before-and-after tracking. Enter your findings and let the workbook calculate compliance across nursing acuity, PHQ, and Section GG automatically — giving leadership an instant facility-wide picture of audit performance without any manual math.

🖨️ Printable Web Browser Version — A clean, print-ready version of the same comprehensive audit framework — designed for facilities that conduct paper-based chart audits, want printed copies for audit binders, or need a format ready for MAC review, internal compliance files, or interdisciplinary team review meetings.

Why proactive PDPM nursing audits matter:
In the current audit environment, Medicare Administrative Contractors and RAC auditors are actively scrutinizing PDPM nursing claims for documentation that fails to support coded nursing categories, Section GG functional scores that don't reconcile across disciplines, PHQ pathways that weren't completed correctly, and HIPPS codes that don't reflect the resident's true clinical picture. A reactive approach — waiting for a denial or an audit request to review your records — is one of the most expensive mistakes a facility can make. This tool puts your team in front of those issues, giving you the opportunity to correct, modify, and protect your reimbursement before the claim is at risk.

What this audit tool covers:

✅ Nursing Acuity — condition-by-condition audit questions covering every qualifying PDPM nursing category with the specific look-back window identified for every condition — from Extensive Services through Special Care High, Special Care Low, Clinically Complex, and beyond — with audit criteria aligned to Myers and Stauffer guidance and real-world Casemix audit standards

✅ PHQ-2 to 9 / Mood Section — a thorough audit of the PHQ interview pathway, staff assessment pathway, depression end-split application, HIPPS code impact, care plan linkage, and signature and completion date compliance — covering the exact documentation gaps auditors flag most frequently

✅ Section GG — Functional Abilities — a rigorous audit of the Section GG observation window, interdisciplinary team documentation, nursing and CNA documentation alignment, therapy documentation reconciliation, not-attempted code justification, usual performance determination, and nursing function score accuracy — built around the documentation standards that hold up under real Casemix audit review

✅ Signatures and Attestation — verification that every staff member who completed any part of the MDS is properly signed, titled, and dated in compliance with RAI Manual requirements

✅ Result and HIPPS Tracking — a built-in result section for every resident capturing whether a modification is needed, the HIPPS code before and after audit, billing notification status, and auditor summary notes — creating a complete, documented audit trail for every assessment reviewed

✅ Facility Roll-Up Dashboard with Auto-Calculated Compliance Percentages (Excel version) — one of the most powerful features of the Excel workbook is the facility-wide roll-up that pulls live data from all ten patient tabs and automatically calculates your compliance percentages across nursing acuity, PHQ, Section GG, and overall performance — no manual math, no separate summary sheet to build. At a glance, leadership can see exactly where the facility is performing well and where gaps exist across the audit sample. This makes the tool an ideal resource for QAPI — providing the data-driven compliance picture needed to identify focused areas of concern, support Performance Improvement Projects (PIPs), track improvement over time across audit cycles, and demonstrate a proactive, systematic approach to MDS accuracy and reimbursement integrity in your quality assurance program.

Who this tool is for:
MDS Coordinators, MDS Consultants, Directors of Nursing, Regional Clinical Directors, VPs of Clinical Reimbursement, QAPI Coordinators, and any leader responsible for PDPM accuracy, casemix integrity, and Medicare compliance in Skilled Nursing. Whether you are conducting a routine internal audit, preparing for a MAC review, responding to a pattern of denials, driving a QAPI PIP focused on MDS accuracy, or onboarding a new MDS coordinator — this tool gives your team a consistent, compliant, and comprehensive audit framework built on the guidance and real-world audit experience that matters most.

Built from the CMS RAI Manual v1.20.1 (effective October 1, 2025), Myers and Stauffer guidance and educational content, and hands-on multi-state Casemix audit experience. RAI Manual specifications are subject to change — always verify audit criteria against the current manual version in effect at the time of each assessment.

📌 Licensed for use by one facility only. Both formats included with a single facility license. Not for redistribution or resale. Full Terms & Conditions provided upon purchase.

Insight MDS & Therapy Solutions
[email protected] | insightmds.com | (561) 223-9122