PDGM: Are you ready?

Small things can have a big impact on an agency's readiness for Medicare's new payment model

Medicare launches its new payment model, the Patient-Driven Groupings Model, in less than 60 days, and home health agencies across the country are scrambling to re-examine processes, policies and workflow to meet the new requirements.

Much of the industry's attention is on expected cash flow shortages in early 2020, as Requests for Anticipated Payment (RAPs) drop to 20 percent from what is currently as much as 60 percent of a full episode payment.

But some of the small things -- such as how well key staff members understand the financial ramifications of their everyday decisions -- could play a significant role in an agency's success, according to Home Health Solutions Owner and Presdent J'non Griffin.

"Agencies need to focus their efforts on getting all staff members ready," she said. "Mistakes and misunderstandings can have a big impact." Here are a few mistakes which can prove costly to agencies under PDGM.

1. F2F misunderstandings An agency's intake staff needs a firm understanding of what is required for a valid face-to-face encounter, as new 30-day billing cycles will make it challenging for agencies to schedule the necessary doctor's visit after start of care. "Even though agencies technically have 30 days after the home health admission to get the F2F, shorter timeframes will make this highly impractical," J'non said. "Instead, it's going to be necessary for intake staff to be identify potential problems with an F2F upfront." (Check out the $24.99 Home Health Solutions Guide to Common F2F Errors sold in The Solutions Shop. Now with complimentary video on F2F documentation.) 2. Vague diagnoses Primary and secondary diagnoses drive case-mix methodology under PDGM, and symptom codes won't make the grade. Some symptom codes are commonly used as primary diagnoses in home health now, including generalized weakness, repeated falls, low back pain and gait abnormalities. But when a symptom code is used under PDGM, the claim will be marked as return-to-provider. Agency staff need to be able to recognize these codes now and contact the referral source to discuss why the diagnoses is not acceptable to Medicare. (Need help knowing what to say to physicians about PDGM? Check out the $19.99 Home Health Solutions "Tools for Tough Talk" package sold in The Solutions Shop.) 3. Changing focus of care

New 30-day billing cycles will require billers, coders and clinicians to regularly communicate so that claims for subsequent periods of home care remain accurate as medical conditions resolve and the agency changes its focus of care. (Check out the Focus of Care Summary package Home Health Solutions sells in The Solutions Shop for $9.99. It explains this issue, offers a sample Focus of Summary form, and a complimentary PDGM Intake Form.) 4. SCIC policy Clinicians who do not fully understand the financial implications to an agency when a patient has a Significant Change in Condition (SCIC) can create costly errors under PDGM. "Agencies need to set new policies for how they will handle SCICs under PDGM," J'non said.

5. Documentation Do staff members fully understand the documentation needed for initial certification and re-certification under PDGM? Shorter timeframes mean agencies won't have time to waste chasing down information which must be submitted with a claim, correcting visit notes missing required items, adding missing evals, etc. (Check out the Home Health Solutions Compliance Checklist, The Paper Trail, sold for $24.99 in The Solutions Shop. It's a quick read, in checklist form, with break-out sections elaborating on required items and offering tips.) "The lack of a fully trained staff has the potential to create ongoing problems for agencies struggling to implement the new payment model," J'non said. "As we count down toward Jan. 1, every agency needs to be focusing on staff training in these areas."