Set to go into effect on January 1, 2020, the Patient-Driven Groupings Model (PDGM) is the largest swooping change to the home health reimbursement system since 2000.

The primary goal of PDGM is to better align reimbursement with patient needs and enable home health agencies to focus less on administrative duties and more on delivering care. This is essential to the benefit of both providers and patients. The basis of success in the value-based care landscape to which all of healthcare is shifting is when clinicians can deliver more focused care which leads to better outcomes.

Transitioning to PDGM will surely create a radical shift in operations for home health agencies. PDGM relies heavily on diagnosis coding, OASIS data, and additional patient data to categorize payment periods into relevant payment categories. Most importantly, PDGM eliminates therapy service thresholds.  

Survival and success under PDGM will depend solely on the readiness of agencies and their staff and strong communication with their coding staff support. Here in, we have already trained our medical coders on the changes brought by the implementation of PDGM.  In addition, we have updated our internal coding software to alert our staff for any trouble codes with a prompt which will allow a secondary coding review. We have also added PDGM tracking to our issue management reports and are updating clients on a nightly basis for PDGM coding issues and problem referrals orders. We are working closely with our clients and training them and their marketers and case managers on revised orders to their MDs, referral sources, and why these changes are needed. We know asking MD for additional orders or changes is a big challenge but we are working with our clients to make this as easy as possible and still maintain compliance during this important transition. Finally, we are monitoring and tracking PDGM coding warnings for patients in November and December 2019 so that by January 1, all coding RECERTs can be properly adjusted as necessary. We assure our clients that we are more than ready and capable to apply the notable updates on care payment for home health providers such as:

  • 60-day payment episodes replaced with 30-day periods
  • Therapy visits are no longer included in determining reimbursement
  • Changes to Low Utilization Payment Adjustments (LUPAs)
  • Adjustments to HHRGs from 153 to 432 categories, including updated measurements
  • Increase in understanding and use of updated ICD-10 coding guidelines
  • Collect complete health histories with accurate and specific diagnosis in our clients’ documentation

Coding Department is on the frontline of outsourced medical coding due to our proven and tested track record of accurate and timely coding and record review services that provide valuable feedback to clinical teams. We attribute this to the skill of our coders and their constant communication between clients when clarification is needed.