Our first in a series of three on PDGM is basic overview of the new payment model
If you are scratching your head about the Subgroups, Clinical Groupings, Questionable Encounters, Comorbidities, etc., we will help you clear it all up!
In the November, 2018 Federal Register, CMS outlined the rationale on moving to a radically different payment approach for home health.
One of the main goals of the PDGM is to clearly account for resource use by highlighting the main reason for home health services.
- In addition to coding guidelines, CMS also looked at clinical practice guidelines and the interventions and skilled care involved in managing the diagnosis at home.
- CMS believes these guidelines provide valuable information for establishing a plan of care and supporting home health resource use. The Patient-Driven Groupings Model (PDGM) uses 30-day periods as a basis for payment, rather than the 60-day model. This however does NOT mean that there will be 30-day episodes for the 485 / Plan of care. A key difference is that there will no longer be Therapy Tiers for reimbursement. Instead, the Clinical Groupings will include all disciplines and along with the subgroup categories listed below, a 30-day payment will be assigned. These 30-day periods are placed into different subgroups for each of the following categories:
- The 30-day periods are categorized into 432 case-mix groups for the purposes of adjusting payment in the PDGM.
- However, there will be times that you will need to do a follow-up OASIS comprehensive assessment and revise the diagnoses when a patient’s status warrants it. This will then result in the billing amounts to be different for those two 30-day periods.
- Overview of the new payment model: Patient-Driven Groupings Model or PDGM
- Reference: Federal Register/Vol. 83, No. 219/Tuesday, November 13, 2018/Rules and Regulations
- Admission source (two subgroups): community or institutional admission source
- Timing of the 30-day period (two subgroups): Early (first 30-day period) or Late (every concurrent payment period after the first period)
- Functional impairment level (three subgroups): low, medium, or high based on the OASIS responses to:
- M1810-upper body dressing,
- M1820-lower body dressing,
- M1840-toilet transferring,
- M1850 transferring,
- M1860 ambulation/locomotion, and
- M1032-hospitalization risk
- Comorbidity adjustment (three subgroups): none, low, or high based on secondary diagnosesTo make it more complex, then there are Clinical Groupings (twelve subgroups) based on the Primary diagnosis:
- Musculoskeletal Rehabilitation
- Neuro/Stroke Rehabilitation
- Behavioral Health Care
- Complex Nursing Interventions
- MMTA – Surgical Aftercare
- MMTA – Cardiac and Circulatory
- MMTA – Endocrine
- MMTA – Gastrointestinal Tract and Genitourinary System
- MMTA – Infectious Disease, Neoplasms, and Blood-Forming Diseases
- MMTA – Respiratory
- MMTA- Other Based on the primary diagnosis, each 30-day period will be placed into one of the 12 clinical groupings. If the primary diagnosis does not fit into one of the 12 clinical groups in the payment model, this is considered a “questionable encounter”
- We will be delving into coding in our next in our PDGM series. Coding is extremely important in PDGM. We at 5 Star Consultants are partnering with our clients to develop strategies to implement now so they are prepared for PDGM when it goes into effect. Start now to learn all of the aspects needed to code in compliance.
- (MMTA = Medication Management, Teaching, Assessment)
Call or Email us today to get information on how we can help you to be prepared for the biggest change in home health since PPS. To find out more about our training options, consulting and coding capabilities, contact us today at [email protected] or 866-428-4040.