Transitioning to the Patient-Driven Groupings Model (PDGM) has already begun to impact operations for home health agencies that are indeed convinced that preparation should be underway. The first two pieces to the puzzle in establishing a Home Health Resource Group (HHRG) and corresponding case-mix weight are Admission Source and Timing. Both of these items are extremely important and will need meticulous attention at the Start of Care (SOC) and, for the Admission Source, that attention will need to continue into subsequent 30-day payment periods.


Admission Source

The first step in grouping the patient will be to establish whether the patient is considered Community or Institutional. In order for the patient to be considered Institutional the patient must be officially admitted and discharged from one of the following facilities where the discharge date is within 14 days of the start of the home health 30-day payment period: Acute Care Hospital, Skilled Nursing Facility, Long Term Care Hospital, Inpatient Rehab or Inpatient Psychiatric Facility.

It is significant to understand that an Emergency Room only visit, an Observation stay or Outpatient surgery does not count as Institutional.

If the patient is admitted to an Acute Care Hospital while in a home health episode the agency will do a Transfer and Resumption of Care (ROC) when the patient returns home. If that return home is within 14 days of the following 30-day payment period that subsequent 30-day period will be Institutional. However, the Final Rule is clear: “we will not categorize post-acute care stays, meaning SNF, IRF, LTCH, or IPF stays, that occur during a previous 30-day period of care and within 14 days of a subsequent, contiguous 30-day period of care as institutional, as we would expect the HHA to discharge the patient if the patient required post-acute care in a different setting, or inpatient psychiatric care, and then readmit the patient, if necessary, after discharge from such setting.” So, if the patient is admitted to a post-acute setting or inpatient psychiatric care the home health agency will discharge the patient and do a brand new admission when the patient returns home.

It is imperative that agencies collect as much information as possible during the Intake/Admission process in order to confirm the status of a facility admission/discharge. The agency will need to report Occurrence Code 61 on the final claim of any 30-day payment period in which Institutional credit is applicable as the result of an Acute Care Hospitalization. The agency will report Occurrence Code 62 when the Institutional credit is the result of a post-acute care admission/discharge and the claim is the first 30-day period claim in a SOC.



The second part of the initial step in grouping patients under PDGM is Timing. Timing is in reference to Early vs. Late. In order for a patient’s 30-day payment period to be considered Early, the patient cannot have been in a home health episode for greater than 60 days. The counting of that 60-day window must be from the natural end of the home health episode, not the discharge date. This is the process that is used under the current Prospective Payment System (PPS) as well. Different from PPS, Early can ONLY be applicable in the first 30-day payment period of a SOC episode. ALL other 30-day payment periods are automatically Late.

Agencies should be determining the Timing status during the Intake/Admission process so as to accurately reflect in the case-mix grouping calculation. This would only need to be evaluated at the SOC due to all subsequent episodes automatically being Late.

The primary thing agencies need to take away from this is that there will need to be as much documentation as possible gathered at intake/admission of the patient in order to have everything needed to appropriately establish the Admission Source & Timing.

Healthcare Provider Solutions understands that thorough preparation is the key to success under PDGM.

We are dedicated to supporting HHAs with a customized PDGM Impact Analysis, outsourced billing solutions, and continued PDGM education. Our seasoned industry professionals are currently guiding agencies nationwide to a smooth PDGM transition.

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