Table of Content
Under PDGM, recertification for home health services, updates to the comprehensive assessment and updates to the HH plan of care continue on a 60-day basis. For HH periods of care that begin on or after January 1, 2020, the unit of payment will be the CY 2020 national, standardized 30-day payment amount. The moment PDGM (The Patient-Driven Groupings Model) takes effect in the year 2020, the Centers for Medicare & Medicaid Services looks to see their new edict change the landscape of home health care operations, specifically with regard to double billing. With PDGM representing the largest wholesale revamp in many years, agencies and providers will need to dedicate significant attention to using this year to ensure proper preparation.
PDGM is a value-based care calculation- which means that agencies are given a certain amount of money and then the agency uses that money to provide the care needed for that patient. Effectively, CMS is saying "Agency, you have $X to do whatever you need to do for the patient, but you're not getting more than that, use it wisely." PDGM hopefully hasn't changed much for the patient. Hopefully the patient is still receiving what is needed to improve. PDGM also reduces the 60-day episode of care payment unit to thirty days.
Careers
CMS finalized a new case-mix classification model, the Patient-Driven Groupings Model , effective January 1, 2020. The PDGM relies more heavily on clinical characteristics, and other patient information to place home health periods of care into meaningful payment categories. One case-mix variable is the assignment of the principal diagnosis to one of 12 clinical groups to explain the primary reason for home health services. The Patient Driven Groupings Model is a case-mix classification model for home health organizations.
The model took effect January 1, 2020 and is the largest change to the reimbursement system in nearly 20 years. The goal of PDGM is to get organizations to focus more heavily on the clinical characteristics of the patients they are serving and eliminate the use of therapy service thresholds. As a diagnosis coding, OASIS review, and data analytics company, we review thousands of OASIS a month. One of the difficulties that agencies have with PDGM is accurate documentation. Only the referring physician or primary care physician can verify and diagnose diseases.
License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition
The intention is to deliver the same amount of care to achieve optimal outcomes, but do within a defined per patient budget. Categorization of 30-day periods into a payment category or Home Health Resource Group based on 432 case-mix groups that are determined by a combination of admission source and timing, clinical grouping, functional impairment level, and comorbidity adjustment. PDGM will undoubtedly have different effects on different agencies. Across the board, the best thing providers can do to prepare for this new horizon is to educate their staffs on what is coming, change some of their behavioral practices, and give attention to rebalancing their patient populations.
Many home health advocates do not like the idea of creating a behavioral adjustment before new regulations take effect. + Behavioral Health ∨+ Addiction & Substance Use Disorders ∨+ Children, Youth & Families ∨+ Resources ∨Count on Relias to support your journey toward better care and financial outcomes with reliable thought leadership and expert advice. Sign up for our newsletter to receive latest news, offers and alerts. First Position - a numeric value representing a combination of the referral source and the period timing . Optional reporting of new Occurrence Codes 61 and 62 identifies the admission source. This license will terminate upon notice to you if you violate the terms of this license.
Partial Payment Adjustment
In order to properly and accurately perform coding and OASIS review, the following is necessary and some are nice to have. Staff on collecting more specific information up front and consider providing a checklist to make data collection easier and more accurate. Here is a great article about PDGM not being the death knell for therapy. Below is what the report would look like for each chart we review.
Seamlessly supplement your clinical assessments with CareScout’s nationwide network of 35,000+ registered nurses. One of the biggest areas of PDGM that has been in the spotlight is in regard to therapy. That balancing act is even more important with PDGM, which must be budget neutral, as mandated by Congress.
What is the Behavioral Adjustment for PDGM?
You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. On Jan 1st2020 PDGM will go into effect, and in spite of the concerns, the new system does have the potential to open new doors of opportunity for some agencies. The system still has room for improvement, and many lawmakers consider it still a work in progress.
With the number of changes in store, inevitably some agencies will contest specific aspects of PDGM’s new requirements. In the past, CMS has already suggested PDGM isn’t budget neutral and is over-paying home health providers. Following 2020, CMS concluded that 2020 base payments were set 6% higher than they should have been. Going into 2020, nearly half of home health agencies planned to decrease therapy utilization, according to a mid-2019 survey conducted by NAHC ahead of PDGM implementation. The general concepts of medicare secondary payer billing will remain the same under PDGM.
Providers who have successfully navigated PDGM and are seeing positive returns from the updated payment model will actively seek agencies who were not as prepared for PDGM and are suffering from its effects. This event explores the strategies for deals, investments and transactions in the home health, home care, hospice and palliative care space. Yet because of the COVID-19 pandemic, any major recalibrations or corrections to PDGM’s foundation have, so far, been delayed, according to National Association for Home Care & Hospice President William A. Dombi. That could begin to change later in 2022, when CMS is gearing up to release its proposed payment rule for 2023.
Grouping to determine the HIPPS code used for payment will occur in Medicare systems and the submitted HIPPS code on the claim will be replaced with the system-calculated code. Home Care Answers helps many agencies across the country with varying census from 15 patients to over 500. We provide a complimentary chart audit to create enough data to give some guidance. Almost without fail, one of our first suggestions is improving documentation. While it’s likely true that PDGM did have some influence on therapy utilization, finding out how much is nearly unquantifiable.
We also help make sure that accurate data is sent to CMS to ensure that potential adjustments and tweaks are based on good data. HHA providers newly enrolled in Medicare on or after January 1, 2019, submit a no-pay RAP and one final claim for each 30 day period. Nurses absolutely can document and send to physician to verify what the nurse documents or if something isn't found in an History and Physical summary. If a diagnosis isn't relevant to a physician, they may not document it, but it could certainly impact the care and outcome of a patient.
For example, a recent stroke patient wants to be able to sleep in his or her own bed, which is upstairs. These are goals that the patient wants to achieve, and can be measurable and justifiable. Therapists should end the evaluation with summary of clinical assessment.
No comments:
Post a Comment