What is the Patient-Driven Groupings Model (PDGM)?
The biggest change the home healthcare industry has seen in decades, Patient-Driven Groupings Model (PDGM) will go into effect January 1, 2020. Axxess is here to help you prepare for, navigate and thrive in this changing environment. Understanding the impending changes will help you stay compliant and improve patient outcomes. The Centers for Medicare & Medicaid Services (CMS) is overhauling the home health prospective payment system as they continue the shift toward value-based care. Proposed changes are projected to increase Medicare payments to home health agencies by 2.1%, or $400 million, in the calendar year 2019.
PDGM’s Impact on Your Operations
PDGM implements a budget-neutral payment approach that shifts payment to better align with patient needs
Admission source, which is determined by the healthcare setting that was utilized 14 days prior to home health admission, will affect reimbursement. Each 30-day period is classified into one of two admission source categories – community or institutional. Patients coming from the community will have a lower reimbursement amount for the payment period than patients coming from an institutional setting.
Home health organizations newly enrolled in Medicare on or after January 1, 2019 will not receive split percentage payments.
Home health organizations enrolled prior to January 1, 2019 will continue to receive split percentage payments until 2020.
Functional Ability and Documentation
With PDGM, it is critical that an accurate assessment is performed to demonstrate functional ability for correct scoring on the OASIS. Secondary diagnoses should also be properly documented as comorbidities can increase reimbursement up to 20 percent.
Documentation at the point of care will be essential with the new 30-day periods. Electronic Health Records (EHR) will facilitate getting paid faster and streamlining operations.
The Key Changes of PDGM
Early episodes are defined as the first 30-days. The subsequent 30-day periods are classified as late.
Each 30-day period is classified into one of two admission source categories – community or institutional – depending on which healthcare setting was utilized in the 14 days prior to home health admission.
Each 30-day period is grouped into one of twelve clinical groups based on the patient’s principal diagnosis which describes the primary reason for which patients are receiving home health services under the Medicare home health benefit.
Learn more about Successfully Navigate the Journey to PDGM. .