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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. This event explores the strategies for deals, investments and transactions in the home health, home care, hospice and palliative care space. Yet because of the COVID-19 pandemic, any major recalibrations or corrections to PDGM’s foundation have, so far, been delayed, according to National Association for Home Care & Hospice President William A. Dombi. That could begin to change later in 2022, when CMS is gearing up to release its proposed payment rule for 2023.
Agencies that developed a solid PDGM strategy are experiencing fewer problems than agencies who did not. They are learning to address any issues as they occur and are adapting quickly. The elimination of therapy volume as a payment determinant. During this process, the voices of home health agencies and industry players will play a crucial role in how PDGM takes shape and reaches its final version. CMS has weighed in with estimations that PDGM will create both winners and losers, with around 50% of homecare agencies experiencing an increase in reimbursements and the other 50% weathering lowered reimbursement rates. Home Health Care News is the leading source for news and information covering the home health industry.
When did PDGM go into effect?
Make sure summaries and narratives tie to OASIS and Plan of Care . Our view is that they can achieve desired results with more efficient use of time and resources. Questionable Encounters refer specifically to the primary diagnosis on the claim. Diagnosis codes that would qualify as a QE in the primary diagnosis spot can be listed as a subsequent diagnosis on the claim. The main concept here is that these diagnoses represent a symptom of the patient’s condition but on their own do not constitute home health eligibility. PDGM is leading to shifts in the way many agencies operate so they can maximize reimbursements under the new model.
HHA providers submit one RAP and one final claim for each 30 day period. Home health agency providers submit one RAP and one final claim for each 60-day episode. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4.
HELPFUL PDGM BLOG POSTS
This lead to therapy overutilization and in some cases fraud. We have several blog articles that also explains PDGM for varioius parts of home health. CMS recognized the potential issue of therapy overutilization and/or fraud with therapy as a component of reimbursement.
PDGM can be complicated, but if nurses and agencies understand the need for documentation, then the picture is much easier to paint for optimal reimbursement. And ensure that the OASIS and other assessment items are consistent and coordinated are successful. Those that do all of this in a timely manner are even more successful. There were a lot of home health agencies that were well prepared for PDGM.
Patient-Driven Groupings Model Toolkit
Like many new rules and policies, it is expected that additional legislation will be introduced after PDGM takes hold, which will improve and update the system. The NAHC has already begun efforts to advocate for legislation that would stop Congress from enacting any new changes based solely on predictions of agency and patient behavior as opposed to actual events. A number of bills which involve areas of PDGM have already been floating around the Senate and the House of Representatives from members of both major political parties.
Typically, CMS releases its proposed payment rule in late June or early July. With two years of PDGM observations and the public health emergency starting to wane, the agency may float big adjustments at that time. Home health care agencies are challenged to develop and implement a plan to meet all the requirements of PDGM and optimize reimbursement. Relias has the tools that can help you properly train your staff, standardize your processes, and manage your staff’s development. CMS sees this as a problem because they want organizations to treat the patient, instead of trying prescribe a treatment that will maximize dollars. To take a proactive stance against this behavior, CMS reduces the amount of money given for certain reimbursements.
PDGM presents one widely recognized challenge for home health agencies involving diagnoses. Estimates suggest that nearly 50% of the diagnoses permitted under the PPS will likely be rejected as ineligible to be classified as primary. With the new policies PDGM presents, case mix will be partially determined by a patient’s functional inabilities. Subsequently this presents a scenario where over 430 combinations can occur under PDGM, while PPS presents only 153.
This threshold is determined by the tenth percentile of visits in each payment group with a minimum of threshold of 2. Two admission source categories used for grouping a 30-day period of care. FISS will be modified to auto-cancel RAP payments on or after January 1, 2020 when the final claim is not received within 90 days of the statement FROM date of the RAP, or 60 days from the paid date of the RAP.
Coding and OASIS were derived to develop an effective score to show through data the condition of the patient at the time of assessment. To avoid LUPA there needed to be more than 4 and to stay under the radar, less than 20 therapy visits. Anything in between would not normally raise many questions. Naturally, many home health agencies and therapists would then provide as much therapy as possible in order to increase revenue for both the agency and therapist.
We also help make sure that accurate data is sent to CMS to ensure that potential adjustments and tweaks are based on good data. HHA providers newly enrolled in Medicare on or after January 1, 2019, submit a no-pay RAP and one final claim for each 30 day period. Nurses absolutely can document and send to physician to verify what the nurse documents or if something isn't found in an History and Physical summary. If a diagnosis isn't relevant to a physician, they may not document it, but it could certainly impact the care and outcome of a patient.
CMS states that these are too vague and they don’t provide enough information to support the need for home health services. Claims that have unacceptable primary diagnoses will be “returned to provider” because CMS cannot assign the 30-day period to a clinical group for payment. Cutting payment periods in half, from 60-day episodes to 30-day periods of care.
In order to properly and accurately perform coding and OASIS review, the following is necessary and some are nice to have. Staff on collecting more specific information up front and consider providing a checklist to make data collection easier and more accurate. Here is a great article about PDGM not being the death knell for therapy. Below is what the report would look like for each chart we review.
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