PDGM Unlikely to be Delayed; Coders Next Home Health ‘Rock Stars’

Despite tenacious rumors, home health owners and operators shouldn’t hold their breath that the Patient-Driven Groupings Model (PDGM) is going to be delayed. All signs still point to a Jan. 1, 2020, implementation date, J’non Griffin, president of full-service consulting company Home Health Solutions LLC told Home Health Care News.

“I can’t say definitively because I don’t work for the Centers for Medicare & Medicaid Services (CMS),” Griffin said, speaking to HHCN Thursday at the Home Health Administrator’s Summit in Las Vegas. “But I really don’t think PDGM will be delayed.”

While the final PDGM language likely won’t be released until late fall, CMS has taken multiple steps that suggest the payment overhaul is a slamdunk.


For example, OASIS-D1 is set to be rolled out in January and already has items needed for payment under PDGM. Additionally, the Patient-Driven Payment Model (PDPM) — the skilled nursing facility (SNF) industry’s version of PDGM — is scheduled for an October launch.

CMS likely wouldn’t go through with PDPM and then flipflop on PDGM, according to Griffin.

“Between those two things, those are pretty good indicators that PDGM is not going to be delayed,” she said. “So, start your preparation now. And if you are just starting right now, you’re already probably behind.”


Home health agencies that have been around since the late 1990s likely don’t need much of a reminder of how disruptive new payment models can be. When the home health industry transitioned to the Interim Payment System (IPS) and then to the existing Prospective Payment System (PPS), roughly 37% of agencies went out of business.

To some extent, those closures were often caused by an agency being heavy in one particular type of service that experienced drastic payment changes, Griffin said.

Come 2020 and beyond, the next wave of closure could be linked to therapy-heavy agencies that can’t adapt to PDGM.

In fact, one therapy-heavy client of Home Health Solutions LLC stands to lose up to $200,000 based on its current census alone, according to Griffin, noting that the figure also takes into account questionable encounters related to primary diagnoses that will no longer be reimbursable.

“Our PPS model has been driven off of therapy,” she said. “CMS has been saying for several years that we need to do away with this therapy-driven model, even though they’re the ones that came up with it. PDGM takes us back to more of a nursing-focused model, not that therapy isn’t important anymore. It’s just not what drives the revenue.”

Instead, overall patient care and complexity will drive revenue, meaning agencies will need to break down internal silos to achieve efficient care delivery.

Coders the ‘rock stars’ of PDGM

Therapists have been the stars of the home health show under PPS, but coders will take center stage once PDGM kicks into action. That’s because two of the Home Health Resource Groups (HHRGs) in PDGM — principle grouping and co-morbidity adjustment — are coding-dependent.

PDGM has 432 HHRGs in total.

“I think coders will be the rock stars,” Griffin said. “They’re going to become the commodity, where therapy is the commodity now. You’re going to have to have a competent coder — not just a coder, but a strong one. And there needs to be checks and balances behind them.”

Currently, about 60% of home health agencies do not have processes in place to double-check their coding work, a recent DecisionHealth survey found.

States in the red

After initial PDGM education, home health agency leaders should conduct a full gap analysis to determine exactly how their operations will change in the world of PDGM, Griffin recommended.

“Home health won’t be the same,” she said.

Agencies in Idaho, Colorado, South Dakota, Utah and Florida should take that message especially close to heart, as those five starts are projected to be among the biggest losers under PDGM, according to a Home Health Solutions LLC analysis of CMS data. Agencies in Idaho, Colorado and South Dakota are all expected to see a more than 11% dip in reimbursement compared to PPS levels.

In contrast, Mississippi, Louisiana, Oklahoma and New York are all projected to see reimbursement levels increase by more than 5% post-PDGM.

“You can’t keep doing business the same way you’ve always done it, just because that’s the way you’ve always done it,” Griffin said. “I hear that a lot out of agencies.”

Companies featured in this article: