About PDGM

The Patient-Driven Groupings Model (PDGM) is the new payment model for Medicare Part A for home health services effective January 1, 2020. It is designed to ensure access to care for vulnerable patients as well as to eliminate the number of therapy visits as a payment factor. We at Casamba want to help you through this change that’s designed to lead to better, more efficient and more cost-effective patient outcomes.

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What constitutes an early versus a late payment period in PDGM?

The first 30-day payment period is considered early. All subsequent adjacent 30-day periods are considered late.

Will late 30-day periods always be considered Community vs. Institutional with respect to admission source?

Late 30-day periods will always be classified as a community admission unless there is an acute hospitalization in the 14 days prior to the late home health 30-day period. (CMS states that home health agencies have the option of whether or not to discharge the patient if the patient is hospitalized for a short period of time.) A post-acute stay in the 14 days prior to a late home health 30-day period would not be classified as institutional unless the patient had been discharged from home health prior to the post-acute stay, which is what CMS states they would expect to occur.

Can patients classified in a Clinical Group other than Musculoskeletal or Neuro/Stroke Rehabilitation receive therapy services?

The Clinical Group reflects the primary reason for home health services, but not the only reason. Patients who require skilled therapy services should receive skilled therapy services, regardless of clinical group assignment.

Are Medicare Advantage plans going to implement PDGM?

PDGM is a payment model for the Medicare Part A Home Health benefit. Other payers, such as Medicare Advantage plans, are not required to adopt PDGM. Home Health agencies should contact individual plans/payers regarding their reimbursement model.

Does information from the OASIS determine payment under PDGM?

Four of the five elements of PDGM are determined by information on the claim: admission source, timing, clinical group and comorbidity adjustment. Functional impairment level is determined by items coded on the OASIS.

What is the Low Utilization Payment Adjustment (LUPA) threshold under PDGM?

Each of the 432 different PDGM payment groups has a LUPA threshold representing the 10th percentile value of visits with a minimum of at least two visits for each group (the range is 2-6 visits in a 30-day period).

Will split percentage payments still apply under PDGM?

Home Health Agencies (HHAs) newly enrolled in Medicare on or after January 1, 2019 will not receive split percentage payments in CY 2020, but will still need to submit a no-pay Request for Anticipated Payment (RAP) at the beginning of each 30-day period to establish the home health period of care. These new HHAs will submit a final claim at the end of each 30-day period. HHAs certified or participation in Medicare prior to January 1, 2019 will continue to receive split percentage payments in CY 2020. These existing HHAs will submit a RAP at the beginning of each 30-day period and a final claim at the end of each period. For the first 30-day period of care, the split percentage payment will be 60/40, and all subsequent 30-day periods will be 50/50.

Do OASIS or certification requirements change under PDGM?

PDGM only affects payment. There are not changes to the requirements for certification/recertification, completion of OASIS assessments, or updates to the patient’s plan of care, all of which continue to be done on a 60-day episode basis.

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