What is PDGM?

Patient Driven Groupings Model (or PDGM), is a new home health reimbursement model under Medicare—the first major overhaul of the home health payment system since 2000. It is slated to begin January 1, 2020.
It requires shorter timetables for physicians orders and signatures and more specific primary diagnoses. 

Codes such as weakness, debility, abnormal gait and fatigue will no longer be valid by themselves. Physician documentation must include the underlying cause of these conditions. In addition, symptom codes (R codes under ICD-10) and many unspecified codes will not be considered valid under this new reimbursement model if the underlying cause isn’t documented.

Please be as specific as possible about the primary patient issue leading to a referral to home health. As always, we will work with you and your team to identify acceptable documentation under this new reimbursement model.

The VNH Intake Team is here to help make the referral process go smoothly. If you have questions, please contact us at 800-575-5162.

The Provider’s Role Under PDGM

Detailed information is vital. It is imperative that agencies have the most specific diagnosis for every patient. Each referral will need:

  • Primary diagnosis for skilled care at home
  • Services requested: validated by diagnoses/conditions. It is critical to use the most specific laterality and location in the patient information.
  • Facility/physicians documents to support the need for home health and services ordered

Timing is critical.

Another big change under PDGM is the move to a 30-day versus 60-day billing. Medicare requires that agencies MUST have all orders including the Plan of Care, back in the office with signature, date, and time before any final billing can be completed.

How You Can Help

  • Be specific about the primary patient issue for which the patient is being referred to home health.
  • Identify what is causing the symptom: i.e. Polyneuropathy related to diabetes
  • Review, sign, and date orders within one week.
  • Consider designating a contact person in your office as a liaison to your local home health and hospice agency to promote continuity and efficiency between the office and agency and reduce delays in patient care.

IMPORTANT: CMS no longer accepts these and many other common diagnoses.

Please consider the following codes (click each one for more info):

Consider: What is the reason the patient is presenting with muscle weakness? Did the patient have surgery or an injury. Did the patient have an infection? Identify what caused the weakness.

Same as weakness guidance. Old age is not a valid diagnosis under PDGM.

What is the abnormal gait related to? Is there an underlying neurological cause? Even variations of abnormal gait such as ataxic gait, difficulty in walking, etc. are not allowed by Medicare.

Superficial injury codes, most used to capture skin tears and abrasions, are NOT allowed as a valid code by Medicare. Consider a laceration code if more appropriate. Why did the patient receive a skin tear? Falling? Loss of balance? Identify the cause rather than the symptoms.

Joint pain without a specific cause is another group of codes not allowed under Medicare’s PDGM. Identify the cause of the pain.

Let’s Work Together

We look forward to working with you through the transition to this new reimbursement model. Together we can develop a plan for an efficient information exchange. Do you prefer fax, electronic mail, hand delivery? Let us know what works for you!

Call the VNH Intake Team at 800-575-5162.

Johanna L. Beliveau, President and CEO

We want to do everything we can to help your patients receive the very best quality of care, as well as provide you with the information you need to make the referral process as easy as possible.