Guides
Plain-language explanations of how post-acute Medicare payment actually works — the systems behind the calculators. Written for clinicians, billers, and coders who want the why, not just the number. Grouped by setting, like the rest of the site.
How PDPM Works
The SNF grouper end to end — the five components, the variable per-diem schedule, and the HIPPS code.
GuideThe Five PDPM Components
What classifies PT, OT, SLP, Nursing, and NTA — and how many groups each has.
GuideAnatomy of a PDPM HIPPS Code
What each of the five characters encodes, and how to read one.
How PDGM Works
30-day periods, five variables, 432 case-mix groups, LUPA, and the HIPPS code.
GuideUnderstanding LUPA
Per-period visit thresholds and the payment cliff.
How Hospice Payment Works
The four levels of care, the two-tier routine rate, the service-intensity add-on, and the cap.
GuideHospice Benefit Periods
Election, recertification, and the face-to-face rule across the benefit periods.
The KX Threshold & Modifier
Therapy thresholds and the targeted medical review process.
GuideThe 8-Minute Rule
How timed treatment minutes become billable units.
IRF Coverage & the 60% Rule
The facility-level 60% Rule, the 13 qualifying conditions, and the case-level medical-necessity criteria.
GuideIRF-PAI & CMG Reference
How the IRF-PAI assessment becomes a case-mix group, and what the 5-character CMG/HIPPS code encodes.
LTCH Site-Neutral Payment
When the standard rate applies versus the lower site-neutral rate, and how the site-neutral amount is set.
GuideLTCH Short-Stay & Interrupted-Stay
The short-stay outlier threshold and the interrupted-stay windows.
How a Medicare Claim Is Built
Bill types, revenue codes, and the UB-04 institutional claim.
How Diagnosis Drives Payment
The role of ICD-10 coding in PDPM and PDGM classification.
What Is PHI?
Protected health information in plain language — the definition, HIPAA’s 18 identifiers, and what “de-identified” really means.
