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CMS announced that the final behavior change adjustment for PDGM 30-day payment rates would be a 4.36% reduction instead of the proposed 8.01% decline. PDGM is leading to shifts in the way many agencies operate so they can maximize reimbursements under the new model. It can take time to hire new people or train current staff to provide high-quality care for these new types of cases.
“This rule… innovates and modernizes home health care by allowing remote patient monitoring,” says CMS Administrator Seema Verma. Industry experts believe the implied endorsement of this technology will spur further technological developments in the home healthcare arena. Threshold; agencies will be facing thresholds of up to 12 visits over 60 days for some HHRGs. Most HHAs are familiar with PDGM, but understanding the impact is more complicated.
PDGM For Dummies - Home Care Answers
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Home infusion therapy services, as required by the Bipartisan Budget Act of 2018. The new permanent home infusion therapy services benefit will begin on January 1, 2021. Defines RPM as the collection of physiologic data that is digitally stored and/or transmitted by the patient and/or caregiver to the HHA. Under PDGM, RPM will not be directly reimbursed, but can be reported as an operating expense.
Low Utilization Payment Adjustment (LUPA)
PDGM clinical grouping is based on the principal diagnosis reported on the claim and CMS designed the groupings to capture the most common types of care provided. According to the Federal Register, the principal diagnosis provides information to describe the primary reason for which a patient is receiving home health services. Under PDGM, each 30-day period of care would be classified through a variety of clinical characteristics and other patient information and then placed into a clinically meaningful payment category or Home Health Resource Group . PDGM will eliminate their use in determining payment, thereby removing any financial incentive to over-provide therapy services and helping to shift the focus towards a more value-based system.
Revenue cycle management organizations like HealthRev Partners can relieve some of the administrative burden of PDGM through expert coding, billing, and billing recovery services. Since revenue cycle management is all we do, we’re able to focus solely on maximizing reimbursements and getting you what you’re owed. New LUPA thresholds that vary by HHRG, based on the 30- day period of care. A partial payment adjustment will apply if a beneficiary transfers from one HHA to another, or is discharged and readmitted to the same HHA within 30 days of the original 30-day period start date.
How PDGM and Medicare Advantage Will Evolve Home Health and Home Care
In compliance with the Bipartisan Budget Act of 2018, PDGM must be budget neutral and the final rule presents it as such. Regression model to assign Functional Impairment points thresholds to each PDGM clinical grouping. There has been a gap of at least 60 days between the end of one period and the start of another. Providers who have successfully navigated PDGM and are seeing positive returns from the updated payment model will actively seek agencies who were not as prepared for PDGM and are suffering from its effects.
There have also been guidance updates to O0110 that is specific to additional treatments. CMS has also updated the definition of rehabilitation therapy in J0520. C0500 had an update in this manual that revises some language surrounding the use of the dash. These are not major changes to how the assessments are to be completed. The changes are primarily to revise some of the actual wording and instructions of how you are to complete the items.
A 30-day period of care will be classified as a Community Admission if the patient has had no acute or post-acute stay within the 14 days prior to admission. As a diagnosis coding, OASIS review, and data analytics company, we review thousands of OASIS a month. One of the difficulties that agencies have with PDGM is accurate documentation. Only the referring physician or primary care physician can verify and diagnose diseases. PDGM replaces the previous reimbursement model called Prospective Payment System which was implemented in 2000.
Average LUPA rate is currently about 8%, and they project a decrease under PDGM to about 7.1%. Some industry analysts are skeptical of the CMS projection and expect the LUPA rate to increase as agencies adjust to PDGM and its many policy changes. 4,878 ICD-10 codes added in the revised PDGM tool, including new codes that were approved to begin October 1, 2018. PDGM eliminates therapy volume as a determinant of payment for HHAs. And we want to make sure you’re equipped with the software and services you need to handle the biggest change in decades – including a whole new set of requirements that could put the squeeze on your productivity and profits. Home Care Answers takes the guesswork out of what you expect to receive for Medicare reimbursement.
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Centers for Medicare and Medicare Services used PPS for 20 years with updates along the way. Over time, CMS continued to issue guidance on important items in reimbursement- particularly diagnosis coding and therapy utilization. CMS wanted all along to have diagnosis coding be at the highest level of specificity and to use therapy for what the patient needed.
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