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Among the many important decisions related to the PDPM transition is the question of whether SNFs and their rehab partners should accept students for clinical affiliations.  As strategy consultants and leaders in therapy, HealthPRO Heritage offers this guidance: 

As PDGM edges closer, there is rising concern and tension around the submission of claims that contain primary diagnoses that do not fall into one of the 12 clinical groupings established by CMS. Such primary diagnoses are known as "Questionable Encounters" (QEs). QE codes are "too vague," meaning the code did not provide adequate information to support the need for home health services. CMS listed 43,287 eligible primary diagnoses codes in their PDGM Grouper Tool. 

Under PDGM, claims for QEs will be sent back to the agency as "Return to Provider" (RTP) since CMS will not be able to assign the 30-day period to one of the 12 PDGM clinical groups. 

Examples of the Top 25 QE Codes:

Start preparing TODAY to guarantee your agency's success in the future. With ~6 months to go, ask yourself: Are you on track for the transition to PDGM? Do you have the right therapy partner?

HealthPRO Heritage at Home has compiled the following PDGM Preparation Checklist that can help organize a plan of action for home health agencies affected by the future of PDGM:

Decisions. Decisions. Since the industry began wrapping their heads around RCS-1 two+ years ago, SNFs continue to weigh the pros and cons of retaining in-house therapy vs. an outsourced model. Questions arise: What does payment reform mean for SNFs with their own program? Is there a financial or operational advantage to transitioning from full service to in-house or a “managed” in-house model?

It can be easy to get lost in the details of PDGM and forget how vital outcomes and ratings are in driving overall agency success.  It’s one of the biggest reasons why appropriately managing therapy in PDGM is a key competency.

In HealthPRO Heritage at Home's recent survey with the National Association for Home Care and Hospice regarding therapy in PDGM, 48% of respondents anticipate less therapy utilization. Agencies should be cautioned on cutting therapy utilization given the focus on functional assessment and outcomes.  Functional assessments - completed best by a skilled therapist - will contribute significantly to payment in PDGM, while also continuing to drive publicly reported outcome measures and star ratings.

Please don't say "Group Therapy" like it's a 4-letter word!

Because many are thinking of the term "Group Therapy" as though it is a curse word, HealthPRO Heritage asks you to instead consider re-imagining what is traditionally thought of as Group Therapy. Let’s RE-think and RE-format Group Therapy with an ultra-valuable, super-educational component. In other words, why not re-invent Group Therapy treatments instead as ‘'Group Education Classes'’?

HealthPRO Heritage at Home partnered with the National Association for Home Care and Hospice (NAHC) to conduct a survey of home health providers to gather industry feedback on therapy utilization under PDGM. HealthPRO Heritage co-sponsored the survey as part of its ongoing effort to bring strategies and solutions to agencies as they prepare for PDGM. Nearly 700 people took the survey and were made up of representatives in every state from freestanding, institutional, health system and government based agencies from both for and not-for profit settings. 

The 2019 RAI Manual is here! The SNF world has been on the edge of their seat in anticipation of how the changes would impact the interdisciplinary team and coding of the MDS assessment.  CMS’ message is clear:  No longer is the manual only for MDS coordinators!  More emphasis on clinical characteristic coding for PDPM case mix group assignment means all disciplines must participate in completion of the MDS. The MDS item sets have been adapted for this shift in the Medicare classification system, requiring significant updates in the go to manual for RAI process.

The Patient-Driven Groupings Model (PDGM) is a game changer, requiring home health providers to explore new business models based on the introduction of new risks and potentially significant financial impacts.

HealthPRO Heritage at Home is leading the industry in readiness for the January 1, 2020 change to the Patient-Driven Groupings Model (PDGM). Success for both our partner agencies and employees will be driven through knowledge and implementation of process and strategy around PDGM.