Download Complete FAQ Guide

When does PDGM take effect?

January 1, 2020

Who does PDGM impact?

For now, PDGM only affects Medicare reimbursement. However, private insurance often follows CMS’ lead so it could eventually be adopted by managed care payers.

Will my reimbursement change?

Most likely. Some will see positive, some neutral, and others may see negative impacts.

What are the key areas that organizations should focus on?

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

What is the behavioral adjustment?

The behavioral adjustment represents a potential 6.425 percent decrease in reimbursement for changes related to LUPAs, comorbidities, and diagnosis codes.

What is a questionable encounter code?

Questionable encounter codes are ICD-10 codes that will NOT calculate a grouper payment under PDGM. Click here for a list of the 25 most commonly used questionable encounter codes.

How is PDGM going to affect maintenance therapy patients?

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.

What should agencies do to prepare for PDGM?

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.