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Intake Isn't Just Intake: Important Steps in PDGM Referral Processing

Five, ten, and fifteen years ago, the intake department was just that: Intake. Taking in the information given to them from a referral source and performing the necessary data entry. As we prepare for the new world of PDGM, the Intake Department will be an integral part of the team.

Come January 1, 2020 under the new PDGM requirements the devil is in the details as it relates to our intake processes and expectations. The importance of having detailed referral information upon acceptance of a patient for home health will be crucial to a smooth initiation of services. Eligibility requirements for a patient to receive home health services will continue to include the need to meet homebound criteria, require skilled services and be under the care of a physician. However, PDGM relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories. 

Ask yourself: Is your Intake Team knowledgeable of what is required moving forward to process an effective referral under PDGM?

Items such as Episode Timing and Admission Source are significantly easier to acquire then an appropriate referring diagnosis that will also fall into one of the 12 Clinical Grouping Categories.  Ultimately it comes down to the fact that we need more information to process an effective referral in PDGM then we had in the past, and in order to meet the eligibility requirements for home care as well as avoid the dreaded Questionable Encounters we need to prepare our team now.

Information needed from the referral source includes:

  • Patient’s primary diagnosis and all secondary conditions and diagnosis
  • Recent procedures or injury associated with the Primary Diagnosis
  • Specific clinical findings making the patient homebound
    • Patient cannot leave home without a “considerable and taxing effort.”
    • Requires the aid of assistive devices, special transportation, or the assistance of another person.
    • Symptoms of the disease process (such as pain, SOB or confusion) worsen when leaving the home.
  • Provide Clinical Documentation including:
    • MD office visit note on letterhead summarizing required info. 
    • History and Physical
    • Clinical, Admission, and Discharge Summary for Acute/Post-acute facility

In order to efficiently process a new referral, your Intake Department needs to have all of the items identified above, and anything that is missing has the potential of delaying the process or ultimately resulting in a claim being Returned To Provider (RTP) due to inaccurate or missing information.  

The Primary Diagnosis submitted on the home health claim will determine the clinical grouping of the claim. A list of all ICD-10 codes and their correlating clinical groupings is available on the CMS website under the PDGM Grouper Tool.

CY 2019 ICD-10 Diagnosis – The 12 Clinical Groupings include:

Musculoskeletal Rehabilitation

MMTA – Cardiac/Circulatory

Neuro/Stroke Rehabilitation

MMTA – Endocrine

Wounds – Post-Op Wound Aftercare
and Skin/Non-Surgical Wound Care

MMTA – Infectious Disease/ Neoplasms/ Blood-forming Diseases

Complex Nursing Interventions


Behavioral Health Care

MMTA – Respiratory

Medication Management, Teaching and Assessment (MMTA) – Surgical Aftercare

MMTA – Other


The following frequently used Primary Diagnosis will no longer be recognized by Medicare as qualifying a patient for Home Health:

  • Muscle Weakness (M62.81)
  • Generalized Weakness (R53.1)
  • Debility (R26.9)
  • Joint Pain (M25.5)
  • Superficial injury codes

The time is now to educate your Intake Team to not only the existing eligibility requirements for home care but also the new components needed for identifying the Clinical Grouping categories.  Empower your Team to feel comfortable asking Physician’s offices and other referral sources for additional information or further detail on what has already been provided.

HealthPRO Heritage at Home’s focus is in providing resources, education, and support to home health agencies preparing for PDGM. Our experts are here to help you prepare, execute, and succeed.

Contact us with your questions. Reach out to us for perspective: homehealth@healthpro-heritage.com

Click here for the full printable article. 


Tags: Home Health, PDGM