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Patient-Driven Groupings Model

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CMS Agency-Level Impact Analysis

The CMS Agency-Level Impact Analysis provides an estimate of the potential impact PDGM could have on your agency. It uses data from the Centers for Medicare and Medicaid Services’ projections that were updated with final 2019 payment rates and reflects methodology changes incorporated into the Final Rule released October 31, 2018.

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Blogs

Clinician assisting a mobility patient

Understanding How PDGM Changes a LUPA

One of the most significant changes the Centers for Medicare and Medicaid Services has made in the new payment model is the threshold for a Low Utilization Payment Adjustment, or LUPA.

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Clinician sitting at a table while viewing the Axxess PDGM resource page on her laptop

A Common Question: Will PDGM be Delayed?

PDGM will significantly change reimbursements for home health organizations, and as our industry learns more about how it will impact day-to-day operations, questions continue to surface.

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Decoding PDGM's Questionable Encounter Codes

The Patient-Driven Groupings Model or PDGM, has exposed a common deficit: correct use of the ICD-10-CM code set's Official Guidelines and Conventions.

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Frequently Asked Questions

For now, it only affects Medicare reimbursement. However, private insurance often follows CMS’ lead so it could eventually be adopted by managed care payers.
Most likely. Some will see positive, some neutral, and others may see negative impacts.
The areas that home health organizations need to assess are:
  • Therapy thresholds
  • LUPAs
  • Non-specific coding
  • Referral sources and the tendency for agencies to focus on institutional referrals rather than community referrals
  • 30-day billing periods
The behavioral adjustment represents a potential 6.425 percent decrease in reimbursement for changes related to LUPAs, comorbidities, and diagnosis codes.
PDGM is a billing initiative and not a clinical one. Maintenance therapy will remain a skilled service under PDGM, however, therapy thresholds will no longer apply.
Educate your staff and referral sources on PDGM. Using data analytics and impact studies, organizations can determine their PDGM risk and develop an individualized plan to mitigate their risk. Ensure that there is alignment of partnerships in coding and software vendors. Along with operational and financial changes, organizations should have a clinical refocus on intra-episode management.

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