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7 Tips to Help You Recover From PDGM’s Behavioral Adjustment

    CMS has anticipated that home health agencies will adjust their documentation and coding practices under PDGM. As a response, CMS will implement a negative behavioral adjustment of 4.36% (based on final rule) to all episodes under the new payment model.

    According to the final rule issued on Oct 31, 2019, the following are the three behavioral adjustments assumed by CMS:

    • HHAs will try to place 30-day episodes into a higher-paying clinical group by changing their documentation/coding practices trying to put the highest paying diagnosis code as the principal diagnosis.
    • By taking into account additional ICD-10-CM diagnosis codes listed on the HH claim (that exceed the six allowed on the OASIS), more 30-day periods of care will receive a comorbidity adjustment than periods otherwise would have received if CMS had only used the OASIS diagnosis codes for payment.
    • To receive full 30-day payments, HHAs will provide one to two extra visits for about one-third of LUPAs that are one to two visits away from the LUPA threshold. 


    Despite this unavoidable adjustment, HHAs can still implement measures to recover from the negative impact on their reimbursements. Here are some tips to avoid further setbacks while still maintaining quality patient care:

    1. Consider all disciplines when scheduling patient visits. Quality patient care should not be compromised even with a limited number of visits.
    2. The LUPA threshold varies per PDGM clinical grouping every 30-day period of care.  You must be familiar with the LUPA thresholds and plot visit schedules with adequate intervals so as not to frontload the visits.
    3. Therapy visits are still an important component of patient care. Schedule therapy visits according to the patient’s medical necessity.
    4. While it is true that certain clinical groupings provide higher reimbursements, you should avoid switching the principal diagnosis with the secondary diagnosis.  Instead, make sure that the ICD-10 coding for the principal diagnosis reflects the primary reason for which patients are receiving home health services under Medicare home health benefits. Remember that this should be properly supported by a physician’s order.
    5. The patient’s risk for hospitalization can affect visit scheduling.  If plotted visits are canceled due to the patient’s admission to an acute care facility, and your actual visits have not reached the LUPA threshold, then your claim may fall under a per visit pay.  Hence, the risk for hospitalization should be properly addressed in the patient plan of care.
    6. Only add PRN visits for complex cases and if really needed for the plan of care —do not add them only for the purpose of avoiding LUPA.
    7. Only add secondary diagnoses that can affect the plan of care and are properly documented by the physician.  Avoid adding secondary diagnoses that are inactive or conditions that have already been resolved for the purpose of comorbidity adjustment.


    Optimize your reimbursements under PDGM —Qavalo’s coders and QA professionals can support your team in streamlining your new revenue cycle while keeping quality patient care.

    Contact us today to learn more about Qavalo’s flexible and cost-efficient PDGM documentation solutions tailored to every agency’s unique needs.