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Published on September 05, 2019

Home Health Care Payment Model Brings Coding, Billing, Ordering Changes

Home Health LogoA new Medicare payment model for home health agencies – the Patient-Driven Groupings Model – goes into effect Jan. 1, 2020. Under PDGM, home health agencies will serve the same types of patients, but some of the information requested from referring physicians will change. The biggest changes are to the diagnosis codes, payment periods and physician orders.

Diagnosis Codes

CMS eliminated most of the unspecified and symptom codes from the PDGM, making specificity of diagnosis important for accurate payment. Additionally, up to 25 diagnosis codes can now be submitted on a claim instead of the six previously considered for reimbursement. Also, there no longer is a therapy threshold.

“By providing more diagnosis codes, our staff gains a more complete patient picture,” said Cheryl Foster, director of NKCH Home Health. “This helps us better assess patients and report back to physicians.”

To optimize reimbursement, NKCH Home Health may request supporting documentation for a symptom-causing diagnosis and any secondary diagnosis.

"This is to meet Medicare's requirement that we code every diagnosis," Cheryl said.

Payment Periods

With PDGM, payment periods move from 60 to 30 days. Each episode is divided into two payment periods:

  • First 30 days with a higher reimbursement
  • Subsequent periods with a lower reimbursement

Physician Orders

Physicians must sign and date every order for each 30-day payment period before NKCH Home Health can submit claims.

“With the 30-day model, we’ll look for faster turnarounds on signed physician orders,” Cheryl said, adding that a new treatment plan is not required for the second 30-day billing period.

She cautioned that any changes, such as to medication frequency or wound care treatment, require new physician orders.