Commonly Asked Questions – and Answers – About PDGM

We’ve been talking with agencies all across the country about the Patient-Driven Groupings Model (PDGM) and there is a common theme to the questions people are asking. In our ongoing effort to help the industry understand and prepare for PDGM, we want to share the answers to those questions with you here:

Will the plan of care and supplementary orders need to be signed before submitting 30 day bills? Under PDGM, the OASIS assessment must be completed, the certification signed, and the plan of care and all other orders must be signed and dated before submitting the final claim for each 30 day payment period.  A RAP may be submitted without the signed orders. These are the same guidelines as under the current Home Health Prospective Payment System (HHPPS).

What are the admission timing categories “early” and “late”? Under the admission category in PDGM, each 30 day period of payment will be classified as an “early” or as a “late” period. The first 30 day period is classified as an early 30 day period and then, all subsequent 30 day periods are classified as late.

If the first 30 day period is early and then, all other subsequent 30 day periods are late, how is this determined for payment since the OASIS assessment time frames are not changing? The timing category assigned to each 30 day period will be based on claims information in the Medicare systems. The system is expected to automatically assign the early or late timing category during claims processing.

Will Medicare Advantage Plans implement PDGM? PDGM is a payment model developed for the Medicare Home Health benefit provided by certified Home Health Agencies. Private payers, such as Medicare Advantage plans, are not required to follow this payment methodology. While some private payers may follow PDGM guidance, it is not required. The requirements from various private payers will vary widely.

How can we find out which diagnoses are currently included in the comorbidity groups? The current diagnoses included in the comorbidity adjustment of PDGM are listed on tabs labeled “comorbidity low/high” within the Updated PDGM Grouper Tool . The grouper tool is one of many PDGM resources located on the CMS Home Health Agency (HHA) Center site’s home page.

Are LUPA thresholds based on 30 day payment periods or 60 day certification periods? LUPAs will continue under PDGM. The LUPA thresholds will vary for each 30 day period depending on the payment group to which it is assigned. The LUPA thresholds range from 2-6 visits.

How can an agency identify which Nursing/Therapy Ratio quartile they have been assigned by CMS? We have an easy to use tool on our website to receive information about your agency’s quartile placement and an overall reimbursement projection. View the tool.

Additionally, every agency is listed with their quartile placement in a spreadsheet labeled as PDGM Agency Level Impacts on the CMS Home Health Agency (HHA) Center site’s home page. The Agency listing is one of many PDGM resources located on the CMS Home Health Agency (HHA) Center site’s home page.

Will Home Health Agencies continue to employ salaried Therapists under PDGM? Therapy services are an important service provided by Home Health Agencies. The PDGM model does not eliminate the need for or dismiss the payment of therapy services. PDGM accounts for the provision of multidisciplinary care through the case mix model based on patient characteristics. Case mix items such as the primary diagnosis, functional impairment level and comorbidity adjustment will account for the multidisciplinary patient needs. Home Health Agency leadership will continue to determine the best model for obtaining therapy services.

What are some best practices that will align therapy service delivery with the individual clinical groups? The Home Health Conditions of Participation (CoPs) continue to require that each patient accepted for home health care receive an individualized and coordinated plan of care. The best approach to ensure safe, effective and efficient care planning is through interdisciplinary care management. Consider using the SBAR approach (Situation, Background, Assessment and Recommendations) for best practice, patient centered care management to provide the right level of care, the right amount of service, by the right discipline at the right time for the right reason.

We will continue to keep you up to date about this important change for our industry.