Focus of care under PDGM

Are your clinicians communicating with coders/billers for second 30-day period of care?

How will your agency handle coding and billing for subsequent 30-day periods of home care under the Patient-Driven Grouping Model (PDGM)?

Many home health agencies are trying to come up with new communication and billing processes to address any changes in the agency's focus of care after the initial 30-day period.

UTIs, pneumonia and many other medical conditions that initially drive patients to home health care typically resolve during the early weeks of the home care episode. Unless there is a mechanism in place to review patient charts and determine whether and how the focus of care has changed, there's some likelihood that, after the initial 30 days of home care, coding and billing will be amiss. Coding should reflect that the condition has resolved and there has been an appropriate shift in the focus of care.

"Shorter billing periods under PDGM are causing agencies to re-think how their clinicians communicate with their coders and billers -- and when that communication should take place prior to subsequent billing," said J'non Griffin, owner and president of Home Health Solutions.

Why it matters

These issues will be of particular concern under the PDGM's primary diagnosis-driven payment methodology because PDGM classifies patients into one of 12 clinical groups depending upon the primary diagnosis.

A change in the agency's primary focus of care would change the primary diagnosis, and likely shift the patient into a different clinical grouping. Since the primary diagnosis is also the basis for determining whether certain co-morbidity interactions trigger a co-morbidity adjustment in payment, having the wrong diagnosis in place for the second 30-day period has the potential to impact agency reimbursement as well as lead to a claim denial.

J'non is recommending agencies have in place a policy to automatically review the focus of care as the first 30-day period of care winds to a close.

"An agency may want to require its clinicians to fill out a very simple form in those last few days, and provide it to the coders/billers before the next 30-day period," she said. "It doesn't have to be complicated. A simple form will collect the information effectively."

Home Health Solutions is offering a sample Focus of Care Summary form in The Solutions Shop, the online store on our web site, for just $9.99.The Focus of Care Summary form comes with a bonus at no extra charge: a sample Intake form for agency use under PDGM.

Click here to visit the store and purchase the form now.