The implementation date for the Home Health Patient-Driven Groupings Model (PDGM) is on or after January 1, 2020. PDGM is an alternative case-mix methodology designed to put the focus on patient needs rather than volume of care. It relies heavily on patient characteristics to more accurately pay for home health services and uses 30-day periods as a basis for payment. These 30-day periods are grouped into 432 home health resource groups (HHRGs) based on admission source and timing, clinical grouping, functional impairment level, and comorbidity adjustment.

PDGM will dramatically impact the way that home health agencies operate. While some agencies may see an increase in payments, some will not. Either way, don’t delay in your preparations! Here are some resources to help.

Patient-Driven Groupings Model (PDGM) Resources

Written and Online Resources

PDGM Impact Tool

Use this tool to get an estimate of what the impact of PDGM could be on your agency. This tool populates CMS’s projections updated with final 2019 payment rates and methodology changes incorporated into the proposed rule.

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PDGM Handbook: Preparation from A to Z

Download this PDGM handbook to learn more about what PDGM is, the key changes included in this payment model that could significantly impact your organization, and how you should start preparing today!

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Intake & Clinical Preparation Tips

Having well-structured intake processes will be vital for success under PDGM. Plan now for changes to your referral and intake processes that will need to occur.

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Coding & Billing Preparation Tips

Under PDGM, your coding and billing teams must operate at peak performance. As PDGM shifts from 60-day episodes to 30-day periods of care, it’s important that you’re ready to avoid any interruption in your payments. We have expert tips to help you succeed.

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Agency Preparation Tips for PDGM

There are a number of things that your agency staff can do together to prepare for PDGM that go beyond departmental readiness. It will take everyone working together to be successful.

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CMS Home Health Agency Center

This CMS webpage has important links for HHAs, inclusive of PDGM resources for both pre and post implementation, inclusive of:

  • CY 2019 HH PPS Case Mix Weights for 60-day episodes into CY 2020
  • CY 2020-CY2022 Rural Add-On-Payment Designations
  • CY 2020 PDGM Case Mix Weights and LUPA Thresholds
  • CY 2020 PDGM Interactive Grouper Tool
  • CY 2020 PDGM Agency Level Impacts

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From Clinical to Coding (ebook)

In this e-book, we’ll discuss how expert coding documentation review and billing services as part of your PDGM preparation strategy can help you succeed.

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Case Study

With HEALTHCAREfirst, one agency found more than just coding clarity…

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CMS Overview

This 8-page high level overview document from CMS provides a simple summary of the Patient-Driven-Groupings Model (PDGM).

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Case Mix Weights, LUPA Thresholds, and Agency-Level Impacts

This Change Request (CR) updates the CY 2020 60-day episode and 30-day base payment rates, the national per-visit amounts, LUPA add-on amounts, the non-routine medical supply payment amounts, and the cost-per-unit payment amounts used for calculating outlier payments under the HH PPS. In addition, the CR revises the initial payment percentage for both initial and subsequent 30-day periods of care under the split percentage payment approach for CY 2020.

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CY2019 Home Health Final Rule

The Patient Driven Groupings Model (PDGM) and a change to a 30-day unit of payment was previously finalized in the CY 2019 HH PPS Final Rule.

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Interactive Grouper Tool

The purpose of the grouping tool Excel file is to help users understand how the payment grouping parameters, which are part of the PDGM, would be used to determine case-mix assignments that are part of the payment calculation under the Home Health Prospective Payment System (HH PPS)., Upon implementation of the PDGM in CY 2020, CMS will provide official grouper software, developed under contract with 3M.

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Split Implementation MLN Matters Article

The Role of Therapy Under the Home Health Patient-Driven Groupings Model (PDGM). This special edition MLN Matters article provides information on the continuing role of therapy under the newly implemented PDGM for home health periods starting on/after January 1, 2020.

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Change Request 11272

This Change Request revises additional sections of Pub. 100-04, chapter 10, to support the implementation of the HH PDGM.

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Online Events

ABCs of PDGM: What it Means to Home Health & How You Should Prepare

Join HEALTHCAREfirst’s regulatory team for an overview of PDGM, including tips and resources to help your home health agency prepare.

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Overview of the Patient-Driven Groupings Model National Provider Call Presentation

Download the complete PDF file of the Presentation for the Overview of the Patient-Driven Groupings Model (PDGM)

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Overview of the Patient-Driven Groupings Model National Provider Call Transcript

Download the complete PDF file of the Transcript for the Overview of the Patient-Driven Groupings Model (PDGM)

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Under PDGM, it will become increasingly more challenging to manage a successful home health business that still focuses on patient care. As these responsibilities continue to become more complex, you should be looking for third-party revenue cycle management services vendors who can alleviate some of these administrative burdens so you can continue to focus on your mission of providing quality, patient-centered care. Learn how HEALTHCAREfirst can get your home health agency ready for PDGM with our comprehensive clinical documentation review, coding, and billing services.

This resource hub is for informational purposes only and is not intended to be, and should not be construed as, legal advice. HEALTHCAREfirst strongly recommends that each agency consult with counsel of its own choosing for legal advice in this matter.