What Physicians Need to Know: Home Health Patient-Driven Groupings Model

In November 2018, CMS finalized a new case-mix classification model, the PDGM, effective beginning 1/1/2020. The PDGM relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories and eliminates the use of therapy service thresholds.

• Your attention to timely signing of orders and the home health plan of care will greatly impact the ability of home health agencies to bill Medicare in a timely way.
• It is very important that the principal diagnosis be as specific as possible. Reimbursement to the home health agency under PDGM for your ordered services in part is based on assignment to one of 12 clinical groups, which represent the primary reason the patient requires home care. Vague, ill-defined, or symptom diagnoses cannot be reported as the principal diagnosis under the PDGM.
• It is also important to include the secondary diagnoses (i.e., comorbidities) as the presence of certain comorbid conditions will also adjust home health payment to help ensure that payment is in alignment with home health resource needs.

For additional information about the continued physician responsibility for certifying eligibility for home health services, please see CMS MLN Matters article SE1436 Revised – Certifying Patients for the Medicare Home Health Benefit.

Related Content

• CY 2020 Home Health Final Rule on Federal Register
• MLN Matters Article MM11081‒ PDGM ‒ Split Implementation
• PDGM ‒ Split Implementation  Change Request 11081