PDGM Diagnosis Coding

By Sharon M. Litwin, January 10, 2020


As discussed in the Home Health PDGM overview, diagnosis coding is a major factor, contributing solely to the Clinical Group and the Comorbidity Adjustment. The coding rules are so complex already under ICD-10, and now with PDGM, there are many more items to take into consideration.

This chapter will deep dive into HH Diagnosis coding under PDGM.

For a review, the Patient Driven Groupings Model (PDGM) went into effect on January 1, 2020. PDGM will require that 30-day periods are used for billing, rather than 60 days. The initial payment, RAP, will be reduced from 60% or (50%) to 20%, and there will be 432 HHRG’s versus 153 under PPS. The Clinical episode of care, including the Plan of Care, will remain at 60 days, causing considerable confusion since 30- day payment periods are occurring within the 60 days and stand alone. Is PDGM rocket science? Well, I tend to think that this is a very complex system where a lot of ongoing education is needed until one can really understand all the facets.

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