Home Health Patient-Driven Groupings Model

March 12, 2019
Rick Gawenda

Effective January 1, 2020, home health services will now be reimbursed under a new system called the Patient-Driven Groupings Model (PDGM). The PDGM changes the unit of payment from 60-day episodes of care to 30-day periods of care and eliminates the therapy thresholds for use in determining home health payment.

Per the Centers for Medicare and Medicaid Services (CMS), the PDGM will assign 30-day periods of care into one of 432 case-mix groups based on the following variables:

• Timing: The first 30-day period of care is an early period of care. The second or later 30-day period of care is a late period of care;

• Admission Source: If the patient was referred to home health from the community or an acute or post-acute care referral source;

• Clinical Group: The primary reason the patient requires home care, represented by distinct clinical groups as determined by the principal diagnosis reported on the home health claim;

• Functional Impairment Level: The patient’s functional impairment level is based on OASIS items for activities of daily living; and

• Comorbidity Adjustment: If the patient has certain comorbid conditions reported on the home health claim, the 30-day period of care can receive a no, low, or high comorbidity adjustment.

To read the CMS transmittal that implements the policies of the PDGM with an effective date of January 1, 2020, click HERE.

Watch for upcoming webinars on this topic to help you prepare for January 1, 2020.

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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

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