Billing, Coding and Intake: Top PDGM Priorities for the Rest of 2019

In July, Home Health Care News heard from five home health providers — big and small — for a check-in on industry progress preparing for the Patient-Driven Groupings Model (PDGM). Now it’s time for the consultants and other industry leaders to weigh in as well.

With less than five full months before PDGM is set to begin, providers should be fine-tuning operations at this point, expert say, singling out billing, coding and intake processes in particular. But while the time for basics has come and gone, it seems some providers are still playing catch up.

HHCN’s conversations with Home Health Solutions LLC, LeadingAge, Axxess and Maxwell Healthcare Associates are below, edited for length and clarity. 

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I see a wide range of PDGM preparation activities. Most providers have had at least a high-level overview of the changes, although a small number of providers haven’t even done this. Some of the [home health] software has also started showing the preliminary codes for clinical groupings so agencies can start familiarizing themselves.

During the rest of the year, agencies need to make sure they have a clear understanding of the model — and agencies should perform their GAP analysis ASAP if they have not already. Operations need to be examined with a concentration on coding … and reviewing billing processes, as these will double with 30-day billing cycles. Clinical management and appropriate utilization is also important.

— J’non Griffin, president and owner of Home Health Solutions LLC

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Regarding PDGM in general, it seems that our members are gearing up to be prepared for Jan. 1. We’ve heard from organizations that are working on evaluating their current practices and educating their teams on the upcoming change. CMS has been proactive in communicating through change requests and MLN Matters articles about billing changes and their BETA Grouper tool to assist in the transition to the new payment system. That said, concerns still exist about aspects of the new payment system that were announced in last year’s final rule, particularly around the impact of the behavioral assumptions and subsequent adjustments.

Once the proposed rule comes out, we’ll have a better idea of the remainder of 2019. If the proposal looks very similar to last year’s final rule, operationally, providers will likely ramp up their projections of the fiscal impact of PDGM on their organizations. We have heard some concerns about cash flow with the proposed changes. It is crucial that providers partner with their organization’s electronic medical record vendor to assure the most informed and smooth transition. We’ve observed some very positive collaborations already in this area. Coding and billing will also come under increased focus with the changes to Low-Utilization Payment Adjustment (LUPA) and Request for Anticipated Payment (RAP).

— Aaron Tripp, VP of reimbursement and financing policy for LeadingAge

*Editor’s note: Tripp’s comments were made to HHCN prior to the July 11 home health proposed payment rule coming out.

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Overall, I would say the industry is marginally prepared, but the level really varies depending on how well providers understand the real intent of PDGM. The best-prepared agencies have insight into their current case-mix, the clinical demographics of their patients and their therapy utilization. The goal of PDGM is value-based care for all patients. We have to start maximizing every visit, which requires collaboration among the entire care team. When it comes to therapy utilization, not enough people truly know how often they use therapists and the patient outcomes based on that level. What’s most important isn’t the overall utilization, it’s what the outcomes look like based on those numbers. By maximizing each visit, we achieve appropriate therapy utilization and optimal patient outcomes.

There must be alignment and education of billing and operational staff members. There are so many factors that have to come together to bill under the increased pressures of PDGM. Intake staff have to get as much information as possible about the patient’s history. Referral sources and physicians have to send and sign orders in a timely manner because, if they don’t, it will hold up the ability to bill for care. When it comes to therapy, I recommend identifying the therapist with the best patient outcomes, and empowering them to develop clinical pathways for optimal utilization and outcomes.

Agencies should leverage technology providers to ensure they are ready with tools to help them succeed under PDGM. It’s important that whatever software is being used can compare what an episode of care looks like today to what it will look like under PDGM. That’s when it starts to click for leaders – they see the impact on the bottom line and can identify where they need to put in the most work to prepare.

There is still time to prepare but providers must act quickly.

— Wendy Conlon, MSPT, VP of client experience for Axxess

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Overall, [providers are] not fully prepared. It’s understandable, though. Providers are working in a state of limbo while they continue to wait to see how the final rule gets vetted out before they cement their PDGM plans. Further, they’re also struggling, justifiably, to maintain operations under the current paradigm before they retrain their staff and rearrange their processes to accommodate the payment overhaul. It’s a tricky time, to say the least, for home health providers, who are doing their best to care for patients within the current parameters while concurrently prepping for tomorrow’s very drastic — and still imprecise — changes.

Piloting, adjusting, finalizing and educating will take priority throughout the rest of 2019. We have a lot of agencies reaching out to us for outside help not only for expertise but also for additional boots on the ground. Agencies’ team members are already working at maximum capacity in the day-to-day. They don’t have time to educate, pilot and edit their processes simultaneously. Agencies will need additional resources to make these monumental changes in a short amount of time. Especially short when you consider PDGM’s final iteration will be presented in late fall, just a couple months before it goes into effect.

— Jennifer Maxwell, co-founder and co-CEO of Maxwell Healthcare Associates