In the CY 2019 Home Health Prospective System Rule Update, CMS finalized the ICD-10 codes that would be “acceptable” to use as a primary diagnosis code under the Patient-Driven Groupings Model (PDGM). The term "Questionable Encounters" (QE) was absent from the proposed and final rules, now there is only “acceptable” or “unacceptable” codes. Learn more and see whether SHP agencies are already phasing out unacceptable codes.
The home health industry is six months away from the new Patient-Driven Grouping Model (PDGM). There is a lot of educational content available to help agencies prepare but much of it reports on PDGM metrics and payments using average values. Using 30-day periods as an overall average can be misleading. It is more meaningful to break out this data into the sequence of periods across groupings like clinical category. In this way one can analyze the impacts of periods to help define the clinical and operational improvements necessary to manage your agencies under PDGM.
Now that we know the Patient-Driven Groupings Model (PDGM) will officially start January 1, 2020, it’s time to dig a little deeper into understanding how the case-mix weights of the 432 PDGM groups were established.
The CY 2019 Home Health Payment System Rate final rule was published last week and, as expected, the Patient-Driven Groupings Model (PDGM) will be implemented for 30-day periods of care starting on or after January 1, 2020. In our blog we provide a summary of changes to the model, such as the expansion of clinical groups from six to twelve, as well as home health PPS Case-mix updates and significant HHVBP changes confirmed in the final rule.
In the CY 2019 Home Health Proposed Rule, CMS shared a level of detail not seen before – an agency specific list of how agencies will fare under the changes they are proposing. Wow. CMS shared the agency revenue impacts of the Patient-Driven Groupings Model (PDGM) versus the current 153-group PPS reimbursement revenue. The range of the revenue impact is quite wide. Looking at the SHP national database for CY 2017, about 17% of the 3.6MM payment episodes in our database had a primary diagnosis code that would be considered a QE under PDGM.