January 1, 2020
For now, PDGM 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:
The behavioral adjustment represents a potential 6.425 percent decrease in reimbursement for changes related to LUPAs, comorbidities, and diagnosis codes.
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.
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.