PDGM: Time for some tough talk

It’s up to agencies to educate physicians about diagnoses not allowed under the new payment model.

With Medicare’s major payment overhaul just 10 months away, home health agencies have some hard conversations ahead with physicians about primary diagnoses which will no longer be allowed under the new Patient-Driven Groupings Model (PDGM.)

It won’t be an easy task to get all physicians on board with the need for more specific diagnoses in order to categorize patients into 12 new clinical diagnosis groupings – particularly since some of the most common diagnoses for home health patients don’t fit into the new groupings, according to Home Health Solutions Owner and President J’non Griffin.

“Coding which does not fall into the allowed groupings will be sent back to the home health agency for correction,” she said.

Common reasons given by physicians for home health referrals are the patient’s weakness, debility or gait issues after a fall – but those medical issues require symptom codes under ICD-1, and symptom codes will no longer be allowed as primary diagnoses under PDGM. Instead, the patient’s underlying condition must be identified as the primary diagnosis for classification into a clinical grouping.

Communication hurdles ahead 

One of the hurdles ahead for home health agencies will be working with physicians to familiarize them with the requirement for more specificity, according to J’non.

"This is the time for agencies to begin having discussions with physicians about the new

requirements and the need for specificity as well as timeliness of signatures on orders" she said. "It's also time to look at internal agency processes to obtain correct information for coding."

Agencies also need to make physicians aware of new 30-day billing timelines under PDGM, which will require expedited signatures for all orders as well as the plan of care.

J'non recommends agencies take the following steps to prepare for important changes under PDGM and pave the way for cooperation from referral sources in making the transition.

Educating physicians

  • Develop a plan for educating all referral sources and physicians.

  • Determine who will spearhead outreach efforts to referral sources for your agency, and clearly define the responsibilities of this person with a timeline.

  • Collect pertinent information about timeline changes and diagnoses groupings under PDGM and compile it into a concise, easy-to-read format which can be quickly scanned and digested. This may be a letter, handouts or a brochure.

  • Set up in-person meetings with referral sources to share the information and get conversations started.

Internal processes

  • Review current agency processes for obtaining information in order to correctly code charts. Make certain there is a viable process in place and agency staff are effectively following it. 

  • Identify the person within the agency who is responsible for this process and review his or her responsibilities, as this role will increase in importance under PDGM. 

  • Discuss the process with both coders and clinicians to identify any weaknesses which need to be addressed. Do clinical efforts support coding throughout the episode of care? How can communication and cooperation be improved? 

  • Determine which diagnosis codes are the most prevalent for your agency. EMR-generated reports, chart audits and CASPER reports may provide this information, which is crucial for a successful transition to the new payment model. 

  • Develop a plan of action to address all vulnerabilities determined during this process. 

     "The transition to PDGM is going to be an enormous undertaking for home health, and it is going to require all segments of our industry working together to ensure an efficient, expedient and successful new way of doing things" J'non said.

HHS can help!

Home Health Solutions knows that talking to physicians about changing regulations can be

challenging. We’ve created two new tools to give you a starting point: a concise and informative brochure highlighting the important information physicians need to know under PDGM, and a helpful handout listing diagnoses which will no longer be allowed under PDGM.

These Tough Talk Tools are available now in The Solutions Shop, our online store, at an introductory price of just $19.99. Click the image below and get your copy of Tough Talk Tools today!