Taking a 20/20 View of PDGM

With the Patient-Driven Groupings Model (PDGM) in effect as of yesterday, it’s time to step back a moment, review your preparations, and remember that the transition to PDGM is a process with both short-term and long-term aspects to it. Taking a 20/20 view of PDGM will lend clarity to your preparations. So, at the start of the biggest “sea change” to hit home health since the Prospective Payment System (PPS) was implemented, here are some thoughts on new beginnings. Patient-Driven Groupings Model (PDGM) is now in effect. QIRT experts on new beginnings.

“No matter how thoroughly you plan, no matter how much you think you know, you’ve never thought of everything.”  — John Flanagan

Final preparation checklist for a 20/20 View of PDGM: 

  • All staff understand the PDGM payment changes
  • Educate staff on their role in implementing PDGM
  • Claims processing staff are ready for the 30-day billing periods
  • Billing staff are ready for the PPS to PDGM transition
  • Coding services are ready with new requirements
  • Review LUPA avoidance strategies
  • Disseminate communication requirement changes
  • Referral source assessment is complete
  • Determine financial resource availability
  • Decide upon performance metrics to be assessed
  • Identify challenges to successful implementation

Prioritize Communication

“The first problem of communication is getting people’s attention.” – Chip and Dan Heath

  • All staff must understand the PDGM payment changes: staff knows how PDGM determines payment PDGM; how this differs from PPS; the importance of accurate information to allow correct coding.
  • Educate staff on their role in implementing PDGM: for each part of the organization, how PDGM affects their workflow and work processes.

Capitalize on Teamwork

“If a thing’s worth doing, it’s worth doing together.” –Michael Bradley

  • Claims processing staff are ready for the 30-day billing periods: this includes the transition period of PPS to PDGM; understanding that claim submission requirements are unchanged—it’s the timing and number of claims submitted that will change.  When to use new occurrence codes is reviewed with staff (for episode timing/admission status).
  • Billing staff is ready for the PPS to PDGM transition: some claims will remain at 60-day/PPS rates in early 2020; Medicare Advantage billing is clarified to see if each plan will follow PDGM or PPS for episodic payments.
  • Coding services are ready with new requirements: Questionable Encounters are minimized; no longer use diagnoses causing these; coders are aware of the increased number of diagnoses able to be used to capture co-morbidity adjustments. Emphasize the access to physician face-to-face encounter visit notes. 
  • LUPA avoidance strategies have been reviewed: the plan of care development is aware of the unique LUPA threshold for that billing period; staff takes pre-emptive steps to minimize unplanned LUPAs.

Encourage Collaboration

“Collaboration, it turns out, is not a gift from the gods but a skill that requires effort and practice.” – Douglas Reeves

  • Communication requirement changes are disseminated: expectations of how often, and how, team members will communicate is clearly posted. 
  • Referral source assessment is complete: what types of referrals are coming from which referral sources have been reviewed. Assess referral source needs for specialty programs. 

Draw from Experience

“Trust yourself. You know more than you think you do.”  — Benjamin Spock

  • Determine financial resource availability: dealing with the significant decrease in RAP monies has been addressed; RAP payments will be less due to 30-day billing periods and the lesser percentage (20%) of that reduced amount that is paid at the start of the billed period.
  • Decide upon which performance metrics to be assessed: days to RAP; days to final claim submission; track the types of claims processed (early/late episode, community/institutional); LUPA percentage; percentage of periods falling into QE status; claim co-morbidity percentages (High, Low, No); days to submit the Plan of Care for physician approval. 
  • Identify challenges to successful implementation: staff buy-in; adjustments to therapy utilization; increased interdisciplinary communication needs; gathering corroborating clinical record content to support coding; staff completing documentation in patient home/as close to service time as possible; dealing with increased volume of claims submissions.

Embrace Learning

“Replace fear of the unknown with curiosity” – Danny Gokey

CMS has posted substantial information on PDGM. A sampling of this includes:

Keep Calm and Care On

Finally, keep a perspective on the changes. With so many things happening, keep a calm objective eye on how things are going to provide the best chance of surviving and thriving in PDGM. We hope this 20/20 view of PDGM gave you some clarity. Some final thoughts:

Above all, remember why you are in this business: patient care. Keep the patient at the center of care: needs, goals, interventions, and outcomes.

If you find all of this overwhelming, QIRT can help. We provide expert quality services for outsourcing coding, OASIS, billing, QA reviews, and more. Let our services relieve some of these burdens so you can focus on care provision. Find out more today at QIRT.com or email ContactUs@QIRT.com.

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