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Corridor’s Insights and Preparations for PDGM

Posted on Thursday, January 24, 2019 6:21 PM

By: Sue Payne, Vice PRESIDENT & Chief Clinical Officer

In November, CMS published the final rule which included information about PDGM becoming effective on or after January 1st, 2020.

As a reminder PDGM (Patient Driven Grouper Model) will be a major change in how home health agencies will be paid for Medicare patients beginning in 2020. The model moves away from therapy driving reimbursement to patient clinical characteristics driving reimbursement. 

PDGM Highlights:

*Patient care will be planned for a 60 day episode just as it is today with orders spanning 60 days, SOC OASIS at the beginning of the episode, and POC for 60 days

*The 60 day episode will be billed in two 30 day units of payment with two RAPS and two final claims

*Based on primary diagnosis, patients will be placed in a Clinical Grouping (MMTA-7 subcategories, Wounds, Complex, MS Rehab, Neuro Rehab, Behavioral)

*Co-morbidities can impact reimbursement so capturing these will be important

*Many of current primary diagnoses will not be ‘acceptable’ for home health in the future and it will be RTP (return to provider) which means touching the record twice

*Functional OASIS questions plus OASIS risk for hospitalization question will determine whether patients are low, medium or high functional level

*It matters where patients were previous to home health admission…..facility based patients will be reimbursed higher than community based patients

*LUPAs will be between 2 and 6 visits under PDGM and they vary according to clinical grouping and/or episode timing

How is Corridor Preparing for PDGM:

Corridor has a PDGM Champion so that our clients and employees are kept up to the minute on this important change

Advisory & Consulting is offering CorridorAccelerate PDGM to assist clients with data analysis and strategic preparations

Corridor Coding Services is monitoring the latest updates related to acceptable diagnoses list for PDGM

Corridor is advocating for the industry with NAHC and PQHH in relation to the diagnoses which will be ‘not acceptable’ under PDGM and how it will impact home health patients

About Corridor

Corridor is the nation’s preferred partner and trusted business advisor to home health and hospice providers, providing quality services and impactful results for 30 years. Focusing on key operational, regulatory and financial challenges, Corridor delivering industry-unique solutions and deep expertise in coding, clinical documentation review, compliance, billing and collections , consulting and provider staff education . At Corridor, we make the business of caring for people Better! For the most important industry updates and news that impacts home health and hospice, please make sure to sign up for our weekly newsletter to receive the latest up-to-date industry information direct to your inbox!

For additional information, please contact Corridor at 1-866-263-3795.

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