While the 3.2% net payment increase for SNFs in Fiscal Year 2026 is welcome news, the devil is in the details of the coding changes. CMS has updated the ICD-10 mappings for the Patient Driven Payment Model (PDPM), moving 33 diagnosis codes to "Return to Provider" (RTP) status.
What is an RTP Code?
Simply put, if these codes are used as the primary diagnosis on the MDS, the claim will be rejected.
The Litigation Angle: False Claims & Audit Risk
Inaccurate coding is not just a billing annoyance; it is a liability risk.
- False Claims Act (FCA): A pattern of using incorrect codes to bypass RTP edits or "upcode" patients into higher acuity categories is a prime target for whistleblowers and OIG audits.
- Quality of Care: If the MDS does not accurately reflect the resident's condition because the facility was "coding for dollars" rather than clinical reality, it undermines the credibility of the entire medical record during a negligence trial.
Strategic Defense
Facilities need to ensure their MDS coordinators are trained on the FY 2026 mappings. Legal teams involved in reimbursement disputes or FCA investigations need experts who can audit the MDS against the medical record to determine if errors were systematic fraud or simple administrative mistakes.
Expert Consulting Services, LLC offers seasoned MDS and billing experts who can unravel the complexities of PDPM coding in high-stakes litigation.
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