Home Health & Hospice Week

Referring docs should be at the head of the list.

If you think you have at least a few months until you need to start Patient-Driven Groupings Model training, think again.

In fact, you should be training this set of folks on PDGM as soon as possible:

• Intake staff. Under PDGM, information on referral source (community vs. institution) is key to reimbursement, as is securing face-to-face documentation so that you can submit a final claim as soon as possible after the 30-day billing period ends. Home health agencies really need to be “educating the liaisons to PDGM now, getting good referral information and adequate face-to-face information,” says consultant J’non Griffin, owner of Home Health Solutions in Carbon Hill, Alabama.

Training intake staff on how to identify “appropriate diagnosis codes from the information provided” is also a wise idea now, advises Diane Magrady, compliance lead with Morton Grove, Illinois-based Pragma-IT, creator of the therapyBOSS therapy documentation software solution. “They should have access to the 12 PDGM diagnosis groups and be able to follow up on primary diagnosis codes that do not fall into any of them,” otherwise known as “Questionable Encounter codes,” Magrady says.

Remember: Once PDGM is in place, claims with a primary diagnosis not in the model’s clinical categories will be returned. To help avoid that, and the cash flow hit it will create, make sure your intake staff are soliciting full diagnosis code information from referral sources before PDGM hits.

• Physicians. In order for your intake staff to get the information they need, your referring physicians also need to be on board. “Begin educating physicians now on the changes that are coming,” urges Pam Warmack with Clinic Connections in Ruston, Louisiana. “They must understand that we will be required to receive far more specific diagnosis codes as so many codes in PDGM will result in a RTP. We also must have any and all orders (as well as F2F) back signed and dated prior to billing each 30-day end of episode claim.”

Sore subject: HHAs also need to give docs a heads up about potential therapy utilization changes. Physicians “must understand that we will not be able to provide the volume of therapy that we have in the past,” Warmack says. “Some MDs believe when they send a referral that says, ‘PT, OT, SLP to evaluate and treat,’ that the agency will automatically admit and provide all this therapy. That is simply not the case.”

One area where docs will be totally on board with this idea is when their practices are involved in bundled payment projects, however, points out attorney Robert Markette Jr. with Hall Render in Indianapolis. Under the Bundled Payments for Care Improvement initiative, Medicare aims to achieve “higher quality and more coordinated care at a lower cost to Medicare,” the Centers for Medicare & Medicaid Services notes on its BPCI website.

Under multiple BPCI models, CMS recoups payments if the spending for a patient goes over a target price. Thus, physicians are “incentivized to get patients strengthened to go to outpatient therapy” as soon as practical for good outcomes, Markette notes. HHAs have seen docs want patients to get around six therapy visits at home, he relays.

• Coders. Under PDGM, diagnosis codes are crucial to two case mix steps — determining the clinical category and setting the comorbidity adjustment (if any). Before even training coders on PDGM, home health agencies must “evaluate their coding process,” Griffin advises. “Who do they have coding? Are they certified? And are there compliance audits behind the coders?” After strengthening coders’ competency, if needed, then agencies can provide specific PDGM education.

While HHAs have a little more breathing room on training these folks, they should draw up a training plan and set a schedule soon:

• Clinicians. “Line up training programs for … nurses who open cases and in-office reviewers to understand all of the nuances of the new system,” recommends Rick Ingber with VantaHealth Consulting. “This is something agencies should do every year in order to understand the minor tweaks in the PPS methodology. However, it is far more important for 2020 because the new payment system is so different and is filled with threats and opportunities.”

You won’t make much progress unless your staff understand why things are going to be different. “Provide education to all staff to support maximum buy-in” for any changes you’re making, says Joe Osentoski with Quality in Real Time in Troy, Michigan. “Share what is changing and why agency processes are changing.”

• Billers. In addition to knowing the ins and outs of PDGM claims submission, billers will need to deal with varying Low Utilization Payment Adjustment amounts and many factors that intersect with the clinical side.