PDGM Part 2 – How Will You Deal with PDGM?

With trying to prepare for the changes that will be brought about by PDGM, do you wonder if you have the right teams in place? With adequate staffing for patient care playing such a large role in our day-to-day operational success, can you imagine not having the right staff to effectively code and review your Medicare episodes, the bread and butter to our companies?
Staff turnover, absenteeism and lack of HH qualified candidates trained in coding and OASIS-D can result in losses of thousands in dollars before you know it. Complicate that with 30-day periods that will be coming with PDGM and it could result in a financial disaster.
The real scenario of how you will be spending your time:
• Insuring staff complete accurate and timely documentation for our 30-day billing.
• Trying to hire HH qualified staff. All too often we see RN’s who come to homecare fresh from the Hospital or SNF with little understanding on how skilled care is provided in the home, HH documentation and how to apply OASIS guidelines to the assessments they perform.
• And to rub more salt in the wound, what about when preceptors training your new staff have not been properly evaluated or trained themselves? Probably because they have only been with you for 6 months and they had to “learn by doing” and the one they learned from was already mentally out the door and could only talk about “why they are leaving”.
• Not to mention you had to eliminate that supervisor position due to financial metrics and you don’t have that person overseeing your episodes anymore?
• Oh, yes, you have assigned it to that one remaining Clinical Manager, and she can do it . . . RIGHT? With all of the other duties she has been assigned to do, please don’t count on it.
• People will typically only do what they feel they can humanly do. It is called self -regulating. It is a common theme in homecare. We think because we have assigned it to someone, they will do it. No, they won’t! They will put it on top of their already full plate, and something will get buried underneath it.

Don’t let that be your coding and OASIS review.
In a time when some agencies will not be able to count on the ready cash flow that your 60 Day episode RAP payment helped with, it will be leaner times for many agencies looking forward to RAP payments on a 30-Day period. There will be pressure on the agencies to “create efficient strategies”, (also known as downsizing) to improve company metrics. Your Coding and Functional scoring will play a large role in your episodic payments. Why trust it in this stressful environment to in house personnel who really do not fully understand the impact PDGM will play?
Consider the following:
• Coding should establish a clear need for skilled services under PDGM.
• Under PDGM, there will be 432 Case Mix Codes from current 153
• There will be over 43,000 ICD-10 codes that are assigned to the 12 Clinical groups
• 12 total Clinical Groups are intended to reflect the Primary Reason for Home Health Services defined by the Principal Diagnosis on the Home Health Claim.
• Claims must have a recognized primary diagnosis ICD-10 code from the APPROVED list of 43,000 codes.
• 43 of the top case mix diagnosis will have at least one comorbidity
• CMS will assign comorbidity levels based on information from the agency claim which affects reimbursement.
• 27 of the top case mix diagnosis will be found in the Neuro/Stroke or Wound Clinical Groups
• Your lower case mix scores will have no comorbidities.
• 29 low case mix scores are associated with low functional impairment based on your OASIS.
• Over 95% of top Case mixes under PDGM will rely on a medium level of impairment
• 35 case mixes are in one of the seven MMTA categories which are associated with a lower reimbursement.
• If your agency uses Abnormality of Gait or Muscle Weakness for example, it is not in the approved 43,000 codes needed to be eligible for reimbursement. Your claim will be returned.

Now why you should consider using 5 Star as your coding company:











Alice Whitehead, RN May 16, 2019
©2019 5Star Consultants, LLC

So, what will YOU do? Don’t wait too late to ensure you are prepared for the upcoming changes with PDGM. Count on a company who is already prepared and can help you survive in this new payment model.

Contact 5 Star Consultants at 866-428-4040 or www.5starconsultants.net

Southern Web SupportPDGM Part 2 – How Will You Deal with PDGM?
Share this post