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Home Care - What Providers Need to Know About PDGM

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Home health agencies need to know the WHY and the WHERE Example: Patient referred to home health for pain in their knee. Provide the cause of pain in the knee. Agencies cannot create a treatment plan without understanding the source, or why, of the problem. Example: Patient is referred to home health for PT and OT for weakness. Provide the diagnoses contributing to the patient's weakness. Agencies can no longer accept M62.81 muscle weakness generalized. Example: Patient is referred to home health for SN, PT and OT to evaluate and treat a wound. Indicate the etiology of the wound. What providers need to know According to CMS, nearly 1 in 5 primary diagnosis codes (20%) are not descriptive enough of a disease, condition or injury to qualify for home health. An Unspecified Diagnosis or Questionable Encounter (also referred to as Unacceptable Diagnoses by CMS) equals questionable need for home health because agencies cannot establish a focused, specific plan of care. Under PDGM: • Diagnosis will be considered Acceptable or Unacceptable • Unacceptable codes will not be reimbursed Home Care PATIENT CENTERED CARE WHAT PROVIDERS NEED TO KNOW ABOUT PDGM Therapy is still included in payments and is a necessary resource; however, the number of therapy visits does not drive reimbursement. Changes the unit of home health payment from 60-days to 30-days. This translates to an increased urgency on timely return of the signed Plan of Care and interim orders. Expect home health agencies to query for more detailed diagnoses via phone or fax if needed to support the reason for skilled home health. Care relies on clinical characteristics. The patient primary diagnosis needs to fall into one of 12 Clinical Groupings. Secondary diagnoses codes could lead to additional reimbursement via a co-morbidity adjustment. SHORTER PAYMENT PERIODS ELIMINATES THERAPY SERVICE THRESHOLDS Allowed providers in diagnosis confirmation • Medical Doctor • Doctor of Podiatry • Doctor of Osteopathic Medicine • Physician Assistant • Nurse Practitioner • MBBS PDGM stands for Patient-Driven Groupings Model. It is the new reimbursement model for Medicare-certified home health patients that will replace the current Prospective Payment System (PPS) model on January 1, 2020.

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