PDGM has arrived – Coding not so much!

By Chris Attaya
January 09, 2020 Home Health

Finally, after a couple of years of preparation and anticipation, the Patient-Driven Groupings Model (PDGM) is underway. For all Starts of Care (SOC), Resumptions of Care (ROC) and recertification assessments beginning as of January 1, 2020, Medicare will now reimburse Home Health Agencies (HHAs) on 30-day periods of care that use a case-mix model based on patient characteristics to determine payments.

The sky is not falling, patients are being seen and no agencies have closed, yet. Yes, there will be significant impacts to agencies. Preparation can help mitigate some issues, but cash flow, therapy utilization, coding and billing issues can still be problematic. 

It’s a little early to get a read on how agencies are doing under PDGM, but one area I was curious about was how much agencies improved on coding “unacceptable” diagnoses (formerly known as Questionable Encounters, or QEs). QEs are primary diagnosis codes that Medicare deems unacceptable to use since they are not specific enough, too vague or not pertinent to home health.  Agencies billing Medicare using these codes will have their claims returned to the provider.

I looked at QEs last summer (Click here to read last year’s blog) and observed coding improvements in the use of these codes from about 14.3% as of January 2017 down to 12.2% as of Dec 2018. When I ran the report as of June 2019, the rates had come down to 8.4%. I wanted to see how they look now that PDGM has arrived.

The good news is the rates have improved, but not as much as I expected. Based on the 30-day periods-of-care that were started, resumed or recertified as of January 1st through January 8th, about 6.0% still have primary diagnosis codes listed as QEs. The top 10 codes look familiar, with muscle weakness taking the top spot as the industry has noted over the last couple of years, including the top 20 we posted here.

ICD-10 Code Description # Periods % of QEs
M62.81 Muscle weakness (generalized) 907 8.4%
R53.1 Weakness 441 4.1%
R68.89 Other general symptoms and signs 402 3.7%
R55. Syncope and collapse 223 2.1%
M54.5 Low back pain 205 1.9%
R69. Illness, unspecified 203 1.9%
R26.9 Unspecified abnormalities of gait and mobility 195 1.8%
R26.89 Other abnormalities of gait and mobility 174 1.6%
R29.6 Repeated falls 167 1.6%
Z51.89 Encounter for other specified aftercare 156 1.5%

Source: SHP National Database of Medicare 30-day Periods with QEs (10,737 total as of 1/8/20).

The top 10 represent 28.6% of all QE 30-day periods, and the top 20 represent 40.4% of all periods. I expect with electronic medical records warnings and the SHP “unacceptable” diagnosis alerts, QE rates will continue to decline. I would note there were 871 unique ICD-10 codes listed as “unacceptable” out of 6,111 primary diagnosis codes posted in the first eight days of the year. That’s a lot of unique codes to start the year. Who said coding was easy?



About the Author
Chris Attaya
Chris Attaya
Vice President of Product Strategy
With more than 30 years of experience in the home health and hospice industry, Chris is responsible for product development and helping clients achieve increased operational and financial performance.