What Occupational Therapists Need to Know about PDGM in Home Health

What Occupational Therapists Need to Know about PDGM in Home Health

The Centers for Medicare & Medicaid Services (CMS) published the Final Rule for the CY 2019 Home Health (HH) Prospective Payment System (PPS) on October 31, 2018. This included a revised case-mix methodology to take effect on January 1, 2020, called the Patient-Driven Groupings Model (PDGM).  Those working in the HH setting have likely already heard of PDGM and may have already seen changes at their agency to prepare for it. What does an Occupational Therapist (OT) working in HH need to know about PDGM and how their profession specifically can prepare for these changes?

PDGM removes the number of therapy visits as a determinant of Home Health Agency (HHA) payment. Because of this, there has been some concern across the industry that patient access to therapy services may be at risk. One must dig deeper into the changes to find out that these changes do not change the value Occupational Therapy brings to their patients. Additionally, the core teachings of Occupational Therapy that give the profession its value in the HH setting continue to apply under PDGM.  Some of those will be pointed out below.

There are several key facts Occupational Therapists need to know about PDGM and its impact on HH payment in 2020.   OTs should be aware of these changes when working with patients in HH:

PDGM FACT:  The principal diagnosis on the HH claim will affect payment by determining the patient’s Clinical Grouping.  This diagnosis should represent the primary reason the patient requires HH services. The Clinical Group will impact payment, and if an ICD-10 code listed as the principal does not correlate to one of these Clinical Groups, there will be no payment for that 30-day payment period.

      • What OTs can do: OTs can help the HH team by explaining what is driving the admission to the HH setting in their documentation. It will be very important for the HH team to determine together the reason for the HH episode for all disciplines. Carefully document a clear rationale why the patient needs care and Occupational Therapy services. This will help whoever at the agency is coding to choose the most appropriate primary diagnosis code for the patient.
      • Core Home Health teaching that is not changing: Documentation of the primary reason the patient needs HH care in the initial evaluation is something that is already a familiar requirement of HH documentation for OTs.

PDGM FACT:  Secondary diagnoses can also affect payment if the patient has certain comorbidities.

      • What OTs can do: OTs know that patients often have several medical conditions and complexities that impact their response to the care given. Conditions that require greater attention or monitoring should be addressed as part of the plan of care. It is important to clearly document all of these areas to help the coders when documenting secondary diagnoses for the patient. How does the patient’s condition(s) impact their ADLs, IADLs and participation in therapy? How does their environment and social situation impact the patient’s ability to make progress?
      • Core Home Health teaching that is not changing:  Documentation of the patient’s conditions that impact their care is already a familiar requirement of HH documentation. Also, HH OTs already add interventions into the patient’s plan of care to work towards the patient’s goals with those conditions in mind.

PDGM FACT:  CMS stated in the Final Rule that “it is the responsibility of the patient’s treating physician to determine if and what type of therapy (that is, maintenance or otherwise) the patient needs regardless of Clinical Grouping. As such, we continue to expect the ordering physician in conjunction with the therapist to develop and follow a plan of care for any HH patient, regardless of Clinical group, as outlined in the skilled service requirements when therapy is deemed reasonable and necessary. Therefore, a HH period’s Clinical Group should not solely determine the type and extent of therapy needed for a particular patient.” In other words, patients should receive the therapy services they require regardless of the assigned Clinical Group.

      • What OTs can do: Work hard to show the value Occupational Therapy has as part of the HH team working together to meet a patient’s HH goals. This includes keeping up with best practice based on current research. Remember the importance of using validated, standardized assessment tools and documenting objective progress by reassessing the patient with the same tools over time.  Focus on function – How does the treatment provided improve the patient’s ability to perform ADLs and IADLs.  And once again, document those assessment results and the patient’s progress every visit.
      • Core Home Health teaching that is not changing: HH OTs have been using standardized assessment tools with their patients to show both limitations and progress all along. HH OTs are also instructed to document ADL and IADL progress every visit and keep the plan of care up to date.

PDGM FACT: The answers to eight OASIS Functional Items will impact payment by determining the patient’s Functional Level:

          • M1800 Grooming
          • M1810 Ability to Dress Upper Body
          • M1820 Ability to Dress Lower Body
          • M1830 Bathing
          • M1840 Toilet Transferring
          • M1850 Transferring
          • M1860 Ambulation/Locomotion
          • M1033 Risk of Hospitalization
      • What OTs can do: OTs can and do routinely assess these areas during the initial evaluation. Then, if some of these areas are determined to be limitations, they are documented on the patient’s plan of care and the OT documents progress at each visit. It is crucial that OTs include documentation for each of these functional areas in their visit notes to allow those members of the team completing the OASIS assessment to accurately code the patient’s status in each of these areas.
      • Core Home Health teaching that is not changing: OTs will continue to play an important role in evaluating a patient’s ADL and IADL status, documenting that status, adding interventions and goals to improve ADL and IADL limitations, and documenting progress towards those goals every visit.

PDGM FACT: PDGM removes therapy visit thresholds as a determinant of HHA payment.

      • What OTs can do: Shift the focus away from the number of visits that are provided and toward how to keep the patient home and safe. Include interventions in the plan of care that will prevent falls and rehospitalizations. HH OTs are skilled at fall prevention and adapting the home for improved safety. HH OTs are also experts at providing recommendations on energy conservation and the use of devices that will improve the patient’s functional status and resume occupations to foster independence, confidence, and quality of life. Show this expertise to your HH team and to your patients so they see the value in Occupational Therapy too.
      • Core Home Health teaching that is not changing: OTs have been the HH experts in ADL and IADL performance, fall prevention, and reducing the risk of rehospitalization all along. Continue to make sure these valued skills are evident to others on the HH team.

Occupational Therapy will continue to play a vital role on the HH team under PDGM.  OTs can use the above suggestions to help support their role in HH under PDGM.


Bogenrief, Jennifer. (2018).  2020 Patient-Driven Groupings Model Will Change HH PPS Payment. OT Practice Magazine.

Bogenrief, Jennifer.  (2019).  Dispelling Myths About New Medicare Payment Models: The Volume to Value Opportunity.  OT Practice Magazine.

Centers for Medicare and Medicaid Services. (2019). Overview of the Patient-Driven Groupings Model.

Krafft & Kornetti.  (n.d). Course 4122: Home Health PDGM:  What Therapists Need to Know Now. Occupational Therapy.

Jennifer Dong

Jennifer Dong is Casamba’s Education and Training Manager. She leads the Casamba Home and Hospice Division’s clinical and product-focused education and training initiatives. Jennifer has been a licensed and NBCOT certified Occupational Therapist for over 20 years, with 13 of those years in home care before joining the Casamba team back in 2013. Her home care experience includes working with patients in the field, as well as clinician documentation, software, and OASIS education. Her previous Casamba roles have also included Clinical Applications Specialist, Project Specialist, and Customer Success Manager.
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