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Home Care / For Physicians / Patient-Driven Groupings Model

Patient-Driven Groupings Model (PDGM)

Patient-Driven Groupings Model (PDGM) is a redesign of the payment system for home health care to be value based rather than volume based. It is focused on the patient’s needs and not on volume of services provided. It will begin January 1, 2020.

For the past year UR Medicine Home Care has been working to modify practices to align with the new CMS changes. We are well positioned with our clinical delivery model to meet the value over volume standards of care. There are two changes that will have the greatest impact on the physician ordering process for authorizing home care services.

Please be assured that we will assist you as we all navigate through these upcoming changes. We appreciate the opportunity to provide care to your patients. Although significant changes are coming, UR Medicine Home Care is well positioned to manage the changes and will continue to preserve and enhance the quality of life for the people and communities we serve by providing comprehensive, high quality health care at home delivered with compassion and integrity.

Home Health Payment Units

There will be a change in the unit of home health payment from a 60-day episode to a 30-day period. CMS believes this will give patients a higher standard of care. This means all orders and Face-to-Face documentation must be returned to us signed and dated prior to billing each 30-day episodic claim. This allows for about a one-week turnaround time from your office back to URMHC in order to meet our billing deadline.

Home Care Referrals

Referrals for home care must include very specific details on services needed.

  • The new model relies more heavily on clinical characteristics/groupings and other patient information to place home health periods of care into meaningful payment categories.
  • The groupings are based on the primary diagnosis reported on the claim. Patients without a primary diagnosis that fits into a clinical group will not be eligible for reimbursement.
  • Effective January 1, 2020, most non-specific, and all symptom codes will no longer be allowed as a primary diagnosis.

Under PDGM, home health care agencies are required to receive far more specific diagnosis codes or face rejected claims. This does not mean that patients with these codes cannot receive services from home care, rather they would need to be tied to a more specific diagnosis. For example, if you place a referral for M25.561 - Pain in right knee, it would result in a rejected claim. Instead you could use the alternative of right knee pain due to baker’s (Popliteal) cyst, patellar tendinitis, or right knee derangement due to old meniscus tear.