PDGM

What is PDGM?

If you’ve been working in Home Health you’ve likely heard about PDGM. This is the new payment model that Medicare rolled out January 1st, 2020. Under this new model, therapy thresholds will no longer be a driver for payment. However, therapy is not going away. Therapy is still necessary to prevent hospitalizations, improve patient outcomes from SOC-OASIS to DC-OASIS, and generally provide functional rehabilitation. For some patients, those in ‘Neurological’ and ‘Musculoskeletal Rehabilitation’ groups, therapy will still be the primary reason for a Home Health referral.

The Numbers

Under the current payment system, a 60-day episode includes, on average, 7 physical therapy visits. If you look at the PDGM model, the average may range between 3-8 therapy visits in a 30-day period, depending upon multiple factors including clinical grouping, institution or community referral, early or late payment period, functional scores, and comorbidities. That's worth remembering, because it shows that number of therapy visits may range from a minimum of 5-6 to as high as 12-16 over 2 30-day payment periods (60 days).

What Should you be Doing?

The industry has already been focused on providing patient-centered care, so you may notice few changes going in to 2020. The difference is that these things will now be codified, however, so if you have not already begun looking at the F&Ds you set, your note timeliness, and how you code your patients -- this is the time to make changes! Focus on Caregivers providing education and reinforcing home exercise programs.

F&D Adjustments

As a clinician, your F&D should be determined by your patient’s specific medical concerns. It should never be a cookie-cutter care plan. If your patient is a recent ortho case, then perhaps the duration is quite short but the initial frequency is quite intensive (PT for 3x per week is common for 2 weeks, and then it either tapers off or ends!) On the other hand, some patients and their caregivers require more time to make adjustments based upon your skilled instruction, so the duration may be longer, while the frequency remains at 1 time per week. This is already common in maintenance therapy cases, but may apply to more home health cases under PDGM. Spreading visits into both 30 day periods, rather than frontloading, may become a strategy for getting patients the therapy they need.

Meanwhile, agencies may focus more on the F&D you are choosing in relation to the patient’s reason for referral as well as the referral source. They may suggest that you spread things out or initially limit your care plan (similar to the managed care or ‘ins auth’ cases) so that habitual front-loading doesn’t impact the patient’s progress and your ability to stay on the case for a longer duration and truly make an impact.

Evidence Based Treatment

Just as medical doctors continue treating patients based upon the latest research, it is important to remember that some things in therapy are variable, while others, like the time it takes to build muscle, may never change. Use evidence based, patient-specific treatment and you will succeed!

Example: Evidence-based exercise prescription for balance and falls prevention

Diagnosis Accuracy

The diagnosis 'muscle weakness’ and other similar vague diagnoses will no longer be accepted by Medicare. Instead, you will be forced to think about why a patient may have muscle weakness. Is it the result of long-standing DM II or osteoarthritis? Maybe a heart condition or COPD has acted as a deterrent. Then those codes should be on the documentation as a reason for therapy. In the Additional Reading is a list of codes to stop using, along with what to code for instead.

Timeliness

Agencies are expected to bill every 30 days, SOCs must be submitted within 5 days to avoid a penalty, and SOCs should include plan of care information from the therapy evaluation. This means timely note submission will be even more important. Evals should be submitted as quickly as possible so that plan of care information can be included on the SOC. Progress notes should be submitted on the same day if at all possible so that agencies can bill and understand what is occurring with their patients.

Additional Resources and Links

Advocacy

Make your voice heard on the home health payment model. The new Patient-Driven Groupings Model (PDGM) that went into effect on January 1, 2020, will make home health payment adjustments based on behavioral assumptions as opposed to evidence or actual provider billing data. Basing payment adjustments on assumptions of provider behavior instead of actual data is arbitrary, could create instability for home health services during this time of reform, and could potentially limit patient access. Visit APTA's PDGM action center to send a message asking your legislators to cosponsor legislation to address this issue. It only takes 2 minutes.