Turn resident clinical data into CMS-compliant MDS 3.0 assessments, then generate the UB-04 / 837I claim that carries the same HIPPS, ARD, and CCN, blocked until iQIES accepts the assessment.
Speaks the standards your MAC and iQIES already require
Every MDS 3.0 assessment carries dual weight: it's the clinical record of a resident's care, and it's the foundation of your facility's reimbursement under PDPM. Get it wrong, and you're exposed to audit risk. Leave revenue opportunities uncaptured, and you're underfunding the care you're already providing. MDS Optima exists to make sure your facility never has to choose between the two.
MDS coding errors don't just cost revenue — they create liability. Inconsistent documentation, unsupported clinical categorizations, and gaps between assessment and care plan are exactly what surveyors and auditors look for, and exactly what exposes facilities to False Claims Act risk.
MDS Optima flags these risks before submission — not after an Additional Documentation Request (ADR) or audit letter arrives. The platform cross-references clinical documentation against MDS coding in real time, surfacing unsupported diagnoses, missing support for skilled services, and coding patterns that don't align with the resident's actual clinical picture. The result: assessments that are defensible, documentation that holds up, and a facility that's audit-ready every day — not just when it's time to prepare for one.
PDPM rewards clinical complexity and specificity — but only when it's captured correctly. Facilities routinely leave reimbursement on the table not because residents aren't complex, but because the documentation doesn't reflect that complexity in a way PDPM recognizes.
MDS Optima analyzes assessment data against PDPM's case-mix classification logic to identify where legitimate, clinically-supported coding opportunities are being missed — across all PDPM components, including Nursing, PT/OT, SLP, and NTA. We help your MDS coordinators and reimbursement teams capture the full, accurate picture of resident acuity, so your case-mix index reflects the actual care being delivered.
This isn't about upcoding. It's about eliminating the gap between the care you provide and the reimbursement you receive for it — with every recommendation grounded in documentation that will hold up under review.
Compliance and revenue optimization are often treated as competing priorities. We built the platform around a simpler idea: accurate, well-supported documentation is the thing that drives both. When your coding is precise and defensible, you reduce audit risk and capture appropriate reimbursement — at the same time, from the same workflow.
MDS Optima is built for MDS coordinators, directors of nursing, and reimbursement teams at skilled nursing and long-term care facilities who need clinical analytics that actually understands the regulatory and financial stakes of every assessment — not a generic data dashboard bolted onto a compliance checklist.
Every PDPM-driving item is auto-populated from the source it actually comes from, then cross-checked against the same grouper CMS uses. No re-keying, no HIPPS surprises.
Section GG reads the ADL flowsheet and therapy plans and applies the RAI rule-of-three automatically, first three episodes within the ARD lookback, most-dependent wins. Every value carries its provenance.
The five PDPM components and the HIPPS code come straight from a live run of the CMS PDPM Java Grouper against the resident's responses. Rates and wage index come from the FY2025 final rule, so the day-1 per-diem is real, not estimated.
A severity-tiered validator runs format, temporal, skip-pattern, consistency, audit-window-drift, and HIPPS-reproducibility checks against the assembled MDS. Fatal findings block submission; warnings surface for review with the per-diem dollars at risk.
The PDPM variable per-diem schedule is wired in, PT/OT taper, the NTA front-load, flat SLP and Nursing, so you can project the full claim total across a plausible stay or the entire 100-day Part A benefit period.
An assistant that retrieves over the RAI Manual v1.20.1 answers coding questions in context, coding rules, skip patterns, CAA triggers, without leaving the item you're working on.
Five services behind an API gateway turn raw resident clinical data into an accepted MDS and the reconciled claim that follows it.
Pulls EHI Export bulk + Marketplace real-time data into staging.
Auto-populates items and surfaces an editable, nurse-facing UI.
Wraps the CMS PDPM Java Grouper to compute the HIPPS.
Assembles, validates, and submits XML; tracks acceptance.
Fires only after acceptance; HIPPS lands on Rev 0022.
The claim can't transmit to the MAC until iQIES has accepted the MDS. The HIPPS computed at finalization must appear on Rev 0022 of the 837I, and the ARD must match the UB-04 occurrence span. A mismatch triggers CMS warning 3935a so we keep the assessment and the claim locked to one set of facts.
Every resident in scope, each with HIPPS, day-1 per-diem, ARD, and assessment type at a glance, searchable by name, MBI, or HIPPS.
Falls, antipsychotics, weight loss, and pressure ulcers rolled up across residents in scope.
CAAs auto-triggered from MDS items, ADL/rehab, mood, nutrition, pressure ulcer, return-to-community.
Coordinators author and lock; viewers read. Security-critical logic, validation and submission, stays code-managed, never admin-configurable.
Pull the assembled assessment, validator report, and claim excerpt as downloadable files.
Book a live walkthrough, or send us a note, we'll get back to you fast.
A 30-minute walkthrough of authoring, the grouper, the validator, and the reconciled claim, on the reference resident or yours.
Questions about fit, pilots, or resident clinical data access? Drop us a line.