Recent CMS Changes for Home Care
 

Patient-Driven Groupings Model (PDGM)

On January 1, 2020 the Centers for Medicare & Medicaid Services (CMS) will institute the Patient-Driven Groupings Model (PDGM). PDGM changes the home health reimbursement model. Other payers may follow suit.

This change affects all home health agencies and will require referral sources to make some changes to referral documentation. PDGM will not change the patient’s Medicare benefit or eligibility, nor will it change the focus that Maury Regional Home Services places on quality patient care and top health outcomes.

Background                                                                

This is the first reimbursement model change in 20 years for home health agencies. With a focus on value-based care, CMS is aligning home health payment with patient care.

Assessment

For referral sources, PDGM will focus on coding the causes, not symptoms, or how sick the patient may be. This means some common admitting diagnoses, such as muscle weakness, will be considered an “Unacceptable Diagnosis” by CMS. Under PDGM, muscle weakness will need to be changed to the underlying cause, such as musculoskeletal disorder or stroke, as the admitting diagnosis. Nationally, there are 24 Top Unacceptable Diagnosis Codes.

PDGM continues to focus on medical necessity and more specific documentation related to the need for home health services. Specific documentation helps ensure a timely start of your patients’ care, prevents re-work for you and your staff and leads to better care.

PDGM is a significant change to the reimbursement model and billing process for the home health industry.  

Recommendations

  • Code the causes leading to the need for home health and be as detailed as possible
  • Be familiar with unacceptable diagnosis codes and their alternative diagnosis codes
  • Respond quickly if more specific information is requested of you
  • Sign the plan of care right away!
  • Let us help you and your staff with PDGM. Maury Regional Home Services is currently undergoing special training.
  • If you have any questions, contact Maury Regional Home Services or Transitional Care Nurse Ashlyn Fields at 931.490.4600.

Below is a list of commonly used ICD-10 codes that will not calculate a group payment under PDGM. Please click on the graphic for a downloadable pdf file.