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With the pandemic, many agencies weren't able to fully implement the learnings and training on PDGM as they understandably had to focus on COVID. We have prepared for a long time to help home health agencies answer the questions they didn't know they had. Many didn't understand the full impact PDGM would have on the agency. We'll answer some of the common questions we get for PDGM and how to improve. Implemented on Jan. 1, 2020, PDGM is the largest overhaul to how Medicare-certified home health agencies are paid in two decades. And normally when CMS implements something of this magnitude, there are ongoing tweaks and changes to make sure reimbursement is fair to both the government and providers.
For example, a recent stroke patient wants to be able to sleep in his or her own bed, which is upstairs. These are goals that the patient wants to achieve, and can be measurable and justifiable. Therapists should end the evaluation with summary of clinical assessment.
When did PDGM go into effect?
When CMS makes changes in policy, they assume that the behavior of home health organizations will change in an attempt to maximize reimbursements. To stay compliant with the model, your organization must have a plan for how you will provide care in the years to come. HHAs may submit the HIPPS code they expect will be used for payment if they run grouping software.
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New LUPA thresholds that vary by HHRG, based on the 30- day period of care. One of the things we see often in documentation is therapy driven goals. Therapists and agencies would do well to listen to patients and develop goals together.
As PDGM was rolled out and explained, many were understandably concerned with therapy and PDGM. There was concern about job losses, reduced pay, reduced work, layoffs, bankruptcies, and everything in between. A federal government website managed and paid for by the U.S. A .gov website belongs to an official government organization in the United States.
Patient-Driven Groupings Model Toolkit
Like many new rules and policies, it is expected that additional legislation will be introduced after PDGM takes hold, which will improve and update the system. The NAHC has already begun efforts to advocate for legislation that would stop Congress from enacting any new changes based solely on predictions of agency and patient behavior as opposed to actual events. A number of bills which involve areas of PDGM have already been floating around the Senate and the House of Representatives from members of both major political parties.
Seeking partnerships within the industry in areas such as telehealth and coding could yield important gains for agencies struggling with adjustment. Referral sources will also play an important role particularly with regard to making sure coders are prepared for the new rules. CMS will be carefully watching the implementation of PDGM, with a special eye on how money is flowing to agencies. Home health agency billing departments should be evaluating and assessing their performance and understanding of the rules throughout this implementation. The decision-making on discipline/visit utilization should not change under PDGM. The plan of care should still be designed to meet the service needs of the patient.
PDGM presents one widely recognized challenge for home health agencies involving diagnoses. Estimates suggest that nearly 50% of the diagnoses permitted under the PPS will likely be rejected as ineligible to be classified as primary. With the new policies PDGM presents, case mix will be partially determined by a patient’s functional inabilities. Subsequently this presents a scenario where over 430 combinations can occur under PDGM, while PPS presents only 153.
CMS finalized a new case-mix classification model, the Patient-Driven Groupings Model , effective January 1, 2020. The PDGM relies more heavily on clinical characteristics, and other patient information to place home health periods of care into meaningful payment categories. One case-mix variable is the assignment of the principal diagnosis to one of 12 clinical groups to explain the primary reason for home health services. The Patient Driven Groupings Model is a case-mix classification model for home health organizations.
When cases “lie outside” expected home care experience by involving an unusually high level of services in 60-day episodes under HH PPS, or 30-day periods of care under PDGM, Medicare claims processing systems will provide extra or “outlier” payment. Outlier payments can result from medically necessary high utilization in any or all of the service disciplines. As in anything, context is essential to understand the whole picture and how we got to where we are. Under the old payment system, PPS, there were three components to determine reimbursement. The combination of the three would determine reimbursement.
You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. On Jan 1st2020 PDGM will go into effect, and in spite of the concerns, the new system does have the potential to open new doors of opportunity for some agencies. The system still has room for improvement, and many lawmakers consider it still a work in progress.
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Grouping to determine the HIPPS code used for payment will occur in Medicare systems and the submitted HIPPS code on the claim will be replaced with the system-calculated code. Home Care Answers helps many agencies across the country with varying census from 15 patients to over 500. We provide a complimentary chart audit to create enough data to give some guidance. Almost without fail, one of our first suggestions is improving documentation. While it’s likely true that PDGM did have some influence on therapy utilization, finding out how much is nearly unquantifiable.
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