The Patient Driven Groupings Model (PDGM) began January 1, 2020, and is in full swing.  Known as the most sweeping change in home health reimbursement since October 2000 and it is holding true to that expectation.  Agencies across the nation are trying to figure out the best practices for being successful under PDGM.  The following are the Top 5 things agencies should focus on to avoid significant losses under PDGM.


1. Intake/Admission Deficiencies

Many of the issues related to losing money on the backend are related to issues that occurred or didn’t occur on the frontend. The following is a list of absolutes that must be gathered during the Intake/Admission process:

      • Referral Order & Confirmation of the physician that will follow the patient in home health.
      • Face to Face acknowledgment that a face to face encounter has occurred and that agency obtaining a signed and dated encounter note where the practitioner addressed/treated the patient for the primary reason the patient requires home health.
      • History & Physical, including Discharge information – the H&P and discharge information needed for multiple reasons, but the most important 3:
        • Medical necessity documentation to support home health
        • Diagnosis coding in the medical record confirmed by a physician
        • Status of the patient stay and discharge date (imperative under PDGM to understand whether the patient was an official admission and if so, the exact discharge date that must be reflected on home health claims)
      • Medicare Eligibility Verification – verifying that the patient is Traditional Medicare patient and establishing if there have been previous home health episodes to determine if the new admission is early or late.


2. Untimely Signed Orders

Agencies must be diligent about getting signed orders returned so that they can efficiently get billing done. Cash flow is an issue under PDGM for all. Requests for Anticipated Payment (RAPs) are being paid at 20% of the anticipated 30-day payment amount, which gives agencies an even greater incentive to get orders back as quickly as possible. Final claims can now be filed at the end of each 30-day payment period, but the glaring requirement to do so is having all orders back from the physician. Following is a recommended scale of a process to follow in getting orders back more effectively if struggling:

Example timeline:

Day 7: Resend orders

Day 12: Call to physician office

Day 15: Escalate to clinical or manager

Day 20: Liaison visit to office


3. Lack of Interdisciplinary Collaboration on OASIS-D1

The OASIS has a huge impact on the PDGM HIPPS code calculation in the aspect of the Functional Impairment Scoring, which comes from the Activities of Daily Living (ADL) section of the OASIS. M1800-M1860 (except M1845) and M1033 are the items used in the calculation. This section includes the ONLY items from the OASIS that are used in the PDGM scoring and this is the only chance for agencies to impact the scoring, from OASIS, as it relates to the increase in reimbursement. From a medical review standpoint, these OASIS items are the first stepping-stone in supporting medical necessity of therapy. It is a well-known fact that therapists are trained to functionally assess patients differently than nurses are trained. It is also a fact that if nursing is ordered then nurses must complete the comprehensive assessment of the patient. In this case, it is IMPERATIVE that there is interdisciplinary collaboration between the nurse and the therapist to ensure the OASIS items are a reflection of the functional status of the patient as will be reflected in the therapy documentation and care plan.


4. Institutional vs. Community Mishaps

Under PDGM there is a significant difference in the case mix weight for a patient that receives Institutional credit and one that is Community. To received institutional credit the patient must be officially admitted and discharged from an acute care hospital or qualifying post-acute facility where the discharge date is within 14 days prior to the home health 30-day payment period beginning. The final claim for the 30-day payment period should include the appropriate Occurrence code with the corresponding discharge date from the facility that triggers the review of Institutional status in the case mix weight calculation. If the Occurrence code is missing from the claim and the facility claim is NOT in the Medicare claims processing system the agency stands to lose the Institutional increase in case mix weight, which could be 40% higher than Community.


5. Lack of Monitoring LUPAs & PEPs

The Low Utilization Payment Adjustment (LUPA) and the Partial Episode Payment (PEP) Adjustment are the two most significant payment adjustments that agencies can receive and sometimes, self-induced. LUPA adjustments occur when the LUPA threshold is not met for the given 30-day payment period. While agencies are going to have LUPAs and it is NOT advised to ever attempt to avoid them 100% there is wisdom in the monitoring of them to ensure that your agency is not allowing LUPAs to occur unnecessarily. Some of the thoughts behind this are primarily missed visits. Having missed visits that do not get rescheduled timely could cause a LUPA to occur. Under PDGM the LUPA thresholds are specific to each of the 432 Case Mix groupings and are likely going to be different from one 30-day payment period to the next. Agencies should monitor each 30-day payment period individually to ensure they under the LUPA threshold for each.
PEP adjustments occur as the result of a patient being discharged and readmitted within or a transfer between agencies during the same 30-day payment period. One of the significant concerns under PDGM is agencies consistently discharging patients and readmitting due to a facility admission in order to receive Institutional credit in the subsequent 30-day period. Agencies should consider asking if a PEP adjustment will result and if so, will the benefit of Institutional credit outweigh the effect of the PEP adjustment.


PDGM is reality and not going anywhere. Healthcare Provider Solutions is dedicated to assisting agencies in reviewing processes in regard to PDGM implementation, outsourced billing solutions, and continued PDGM education. Our seasoned industry professionals are currently guiding agencies nationwide to a smooth PDGM transition.


PDGM Success


2020 is NOT just about PDGM. Watch our FREE webinar to ensure success in 2020 beyond PDGM. This December 2019 update included information on the required update to iQIES, the mandated full implementation of the Medicare Beneficiary Identifier, the blocked access to the Common Working File, update to the HHCAHPS Survey, the OASIS-D1 implementation requirements, and more.