When the Patient-Driven Groupings Model (PDGM) was implemented on January 1, it initiated 30-day billing periods that categorize diagnoses into 432 case-mix groups t to determine payments.
While many home health agencies are adapting to this payment model, there are still a number of agencies who do not fully understand this methodology, and more importantly, how to streamline their operations to ensure they will thrive.
The role of the clinical manager is vital in not only ensuring the agency understands these new regulations but also instituting changes to clinical operations. The new case-mix calculations may seem complex but understanding each individual component can lead to better payment outcomes.
The Anatomy of PDGM
- Admission source (two subgroups): community or institutional
- IMPORTANT: For the patient to be considered institutional, the patient must be officially admitted and discharged from one of the following facilities where the discharge date is within 14 days of the start of the home health 30-day payment period: acute care hospital, skilled nursing facility, long-term care hospital, inpatient rehab or inpatient psychiatric facility.
- AGENCY STRATEGY: Critical information must be collected during the intake/admission process. The field nurse and intake staff should be trained on proper patient interviewing techniques and what constitutes an inpatient facility admission.
- IMPORTANT: Early timing only applies in the first 30-day billing period. All subsequent episodes are considered late.
- AGENCY STRATEGY: An accurate assessment must be made during the intake/admission process to review episode timing. Intake staff should verify whether a patient used home health services within 60 days prior to SOC admission. If so, this would constitute late timing.
- IMPORTANT: The primary diagnosis places the patient in one of the 12 subgroups. For example, if a patient’s principal diagnosis is a Stage II pressure ulcer of the right buttock, the patient would be placed under the wound clinical grouping.
- AGENCY STRATEGY: Coding will have a substantial effect on the calculation of the case-mix weight. Agencies must ensure that they have a strong coding team that is trained in the new ICD-10 guidelines under PDGM. The intake/admission process should allow for more time spent on allocating current and accurate history and physicals from a variety of sources, such as primary physicians, inpatient facilities, and specialty physicians, to ensure that the most pertinent primary and secondary diagnoses are utilized. Partnering with the right technology partner and effectively using its home health software (ungroupable diagnosis alerts, diagnosis and payment modeling tools etc.) are crucial to long-term success.
- IMPORTANT: Higher scores will be assigned to patients whose responses indicate higher functional impairment and a higher risk of hospitalization.
- AGENCY STRATEGY: More than ever, field clinicians should receive current education on the intention of these specific M-items, and the agency should standardize how assessments are completed. It is also important that field clinicians adopt a “show me” assessment style with patients, rather than just asking them a series of questions about their current functional status and accepting their description.
- IMPORTANT:
- Low comorbidity adjustment: There is a reported secondary diagnosis that is associated with higher resource use.
- High comorbidity adjustment: There are two or more secondary diagnoses that are associated with higher resource use when both are reported together compared to if they were reported separately. That is, the two diagnoses may interact with one another, resulting in higher resource use.
- No comorbidity adjustment: A 30-day period would receive no comorbidity adjustment if no secondary diagnoses exist or none meet the criteria for a low or high comorbidity adjustment.
- AGENCY STRATEGY: The comorbidity adjustment is directly linked with the secondary diagnosis, which impacts the resources used, thus directly affecting reimbursement. All patient diagnoses must be identified and placed on the patient’s claim. Partnering with the right technology partner on a home health software that effectively captures comorbidity diagnoses and payment modeling tools is crucial to maximizing reimbursement.
Axxess is your technology partner for PDGM success, home health education and solutions. Find more information on our PDGM resource webpage, in our Help Center, or request a demo of our solutions today.
