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Getting Your Agency Set for PDGM Rollout

    The new Patient-Driven Groupings Model (PDGM) proposed by CMS will take effect on January 1st, 2020.  Drastic changes in the home health industry are anticipated as this modification will greatly affect the process by which therapy services are reimbursed. Furthermore, this switch will enforce new case-mix weight calculations and shorter payment periods.

    With only a few months before the onset of PDGM, your agency should now start updating your documentation processes and projecting your workforce needs. This will be your guide on doing just that.


    Notable PDGM Updates

    30-Day Periods
    Perhaps the most notable change in the new payment system is the shortened payment period from the current 60 days to 30 days, as required by the Bipartisan Budget Act of 2018.

    Therapy Reimbursements
    PDGM is developed to eliminate overpayment of therapy services. These payments will now require stronger clinical evidence, which will facilitate the Functional Impairment classification of PDGM’s new payment groupings.

    HHRG / Payment Groups
    Based on an OASIS assessment, 30-day periods under PDGM will be classified under a variety of patient information and other clinical characteristics, such as admission source, timing, clinical grouping, functional impairment and comorbidity. This will result in 432 different HHRG combinations (as opposed to 153 under PPS) for each of which CMS will generate a PDGM case-mix weight.

    Low Utilization Payment Adjustments (LUPA)
    Under PPS, the current payment system, there is a four-visit LUPA threshold within 60-days for every patient. With PDGM, thresholds will vary per HHRG over a 30-day period. Agencies are then required to follow new thresholds of 3 to 12 visits over 60 days for HHRGs, meaning agencies should closely monitor different LUPA thresholds for each patient.


    What Can Your Agency Do?

    Intake and Orders Management
    At the front-end of the revenue cycle, you’ll need an efficient process of gathering necessary documentation and tracking orders. Start by educating your intake team with the new requirements and target timelines. Subsequently, streamline your communication process from referral to admission for quick capture of critical information, accurate coding, and timely billing.

    Coding under PDGM will be greatly affected as well. As you remember, the principal diagnosis determines which clinical group a patient will be included in —make sure it is reflected clearly on the referral notes. Likewise, all secondary diagnoses should also be properly documented for optimal comorbidity adjustments.

    The number of claims submissions will nearly double under PDGM’s shift to a 30-day payment period. Therefore, agencies must review their claims processing to deliver, document, and bill for care twice as often.

    The first 24-48 hours from the start of care (SOC) are critical to optimizing reimbursements — clinicians must assess the patients’ needs, then document a plan of care (POC) as soon as possible. Billers and clinicians should stay on top of each patient’s LUPA thresholds by monitoring the number of visits on the POC.

    OASIS Assessment
    Agency processes and timelines for OASIS completion and submission must be reviewed. This is because while OASIS assessments are still required every 60 days, LUPA thresholds are determined by HHRG classifications within the 30-day billing periods. Thus, timely completion and thorough documentation of patient assessments and ongoing reassessments is imperative. In light of this, staff knowledge on the importance of functional status assessments is critical as it relates to PDGM functional impairment levels.

    With PDGM’s shorter payment periods and doubled documentation requirements, agencies should carefully plan out their workforce. Regardless of conducting staff training to adjust to the new requirements and timelines, increasing manpower is inevitable. Employing technical experts, such as specialized solutions providers, and repositioning your in-house team for intake and billing processes may be your solution to these problems.


    Get Ready with Qavalo

    Qavalo’s responsive tools and process solutions have been specifically developed to assist agencies like yours achieve an easy and efficient PDGM transition. Our trained and licensed professionals are ready to work alongside your in-house team in preparation for all the changes coming on January 1st.

    Let’s discuss how we can collaborate and securely usher your agency into the new PDGM era. Contact us >