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Under PDGM, recertification for home health services, updates to the comprehensive assessment and updates to the HH plan of care continue on a 60-day basis. For HH periods of care that begin on or after January 1, 2020, the unit of payment will be the CY 2020 national, standardized 30-day payment amount. The moment PDGM (The Patient-Driven Groupings Model) takes effect in the year 2020, the Centers for Medicare & Medicaid Services looks to see their new edict change the landscape of home health care operations, specifically with regard to double billing. With PDGM representing the largest wholesale revamp in many years, agencies and providers will need to dedicate significant attention to using this year to ensure proper preparation.
PDGM is a value-based care calculation- which means that agencies are given a certain amount of money and then the agency uses that money to provide the care needed for that patient. Effectively, CMS is saying "Agency, you have $X to do whatever you need to do for the patient, but you're not getting more than that, use it wisely." PDGM hopefully hasn't changed much for the patient. Hopefully the patient is still receiving what is needed to improve. PDGM also reduces the 60-day episode of care payment unit to thirty days.
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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.
The model took effect January 1, 2020 and is the largest change to the reimbursement system in nearly 20 years. The goal of PDGM is to get organizations to focus more heavily on the clinical characteristics of the patients they are serving and eliminate the use of therapy service thresholds. As a diagnosis coding, OASIS review, and data analytics company, we review thousands of OASIS a month. One of the difficulties that agencies have with PDGM is accurate documentation. Only the referring physician or primary care physician can verify and diagnose diseases.
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Before the public health emergency, there was a wariness attached to scheduling therapy visits because of the onset of PDGM. But after it, there was a shift in thinking, according to experts. Experts warned that decreasing therapy recklessly would be potentially dangerous for patient outcomes.
Many home health advocates do not like the idea of creating a behavioral adjustment before new regulations take effect. + Behavioral Health ∨+ Addiction & Substance Use Disorders ∨+ Children, Youth & Families ∨+ Resources ∨Count on Relias to support your journey toward better care and financial outcomes with reliable thought leadership and expert advice. Sign up for our newsletter to receive latest news, offers and alerts. First Position - a numeric value representing a combination of the referral source and the period timing . Optional reporting of new Occurrence Codes 61 and 62 identifies the admission source. This license will terminate upon notice to you if you violate the terms of this license.
Partial Payment Adjustment
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.
Seamlessly supplement your clinical assessments with CareScout’s nationwide network of 35,000+ registered nurses. One of the biggest areas of PDGM that has been in the spotlight is in regard to therapy. That balancing act is even more important with PDGM, which must be budget neutral, as mandated by Congress.
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.
Therefore, with PDGM therapy was removed as a component of the reimbursement calculation. Home Health Agencies now use a combination of diagnosis coding and OASIS data to determine the reimbursement rate. Other components used in the calculation is episode timing (early/late), referral source (institutional/community)- which institutional results in an automatic 10% increase in reimbursement. With all of this data together, a reimbursement amount is determined- independent of the amount of visits/therapy needed.
Providers who have successfully navigated PDGM and are seeing positive returns from the updated payment model will actively seek agencies who were not as prepared for PDGM and are suffering from its effects. This event explores the strategies for deals, investments and transactions in the home health, home care, hospice and palliative care space. Yet because of the COVID-19 pandemic, any major recalibrations or corrections to PDGM’s foundation have, so far, been delayed, according to National Association for Home Care & Hospice President William A. Dombi. That could begin to change later in 2022, when CMS is gearing up to release its proposed payment rule for 2023.
Coding and OASIS were derived to develop an effective score to show through data the condition of the patient at the time of assessment. To avoid LUPA there needed to be more than 4 and to stay under the radar, less than 20 therapy visits. Anything in between would not normally raise many questions. Naturally, many home health agencies and therapists would then provide as much therapy as possible in order to increase revenue for both the agency and therapist.
We also help make sure that accurate data is sent to CMS to ensure that potential adjustments and tweaks are based on good data. HHA providers newly enrolled in Medicare on or after January 1, 2019, submit a no-pay RAP and one final claim for each 30 day period. Nurses absolutely can document and send to physician to verify what the nurse documents or if something isn't found in an History and Physical summary. If a diagnosis isn't relevant to a physician, they may not document it, but it could certainly impact the care and outcome of a patient.
It is not guaranteed that this will occur during the PDGM implementation, but providers should be aware of the potential delays. Finally, National Association for Home Care & Hospice performed an independent review using example cases for PDGM periods starting on various dates. This analysis found that in most cases agency cash flow would not return to pre-PDGM levels until approximately March 2020. The impact will be different for each provider, but our recommendation is that providers prepare for this potential risk. PDGM changes the method for calculating payments, including the changing of 60 day episode payments to 30 day payment periods and the removal of the therapy thresholds. PDGM will change the payment rates for agencies as compared to our current PPS model.
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