Top PDGM Therapy Myths Busted

With the implementation of the Patient-Driven Groupings Model (PDGM) just months away, therapy-heavy providers are still trying to determine what the payment overhaul will mean for them.

With the uncertainty comes misconceptions, which can end up hurting a provider’s bottom line if taken to heart.

One of the biggest myths associated with PDGM is that scaling back the number of times a therapist is sent into the home will be beneficial when it comes to reimbursement.


As such, some providers have made plans to lower therapy utilization. In fact, about 25% of providers that participated in a recent National Association for Home Care & Hospice (NAHC) survey said they plan to reduce therapy utilization by more than 10% in 2020.

Historically, therapy has been a reimbursement-booster for home health agencies, but it will no longer automatically drive payment under PDGM. Instead, patient characteristics and outcomes will hold more weight.

Despite the changes, claims that Medicare will stop reimbursing for therapy services all together are patently untrue — and cutting therapy drastically is unwise.


Specifically, agencies have discussed capping visits at six, 10 or 14, according to Bud Langham, chief clinical officer of the home health and hospice segment of Encompass Health Corporation (NYSE: EHC).

“My response in all of these situations is that this is not the way to go,” Langham said, speaking on a panel at the 2019 HHCN Summit in Chicago. “None of this is patient-centered, none of this is individualized care [and] it will come back to bite you. Please go back and have another meeting. Have a thoughtful approach to how you are going to take care of patients.”

Langham was joined on the panel by J’non Griffin — president of Alabama-based consulting company, Home Health Solutions LLC — who also urged providers to move towards a patient-centered, evidence-based care plan rather than slash therapy. She warned that the Centers for Medicare & Medicaid Services (CMS) would be on high alert for agencies that blindly made cuts.

“CMS has said they will come after you if they just see a total cut in visits all of a sudden,” Griffin said. “You need to have a clear business plan going into PDGM.”

While experts approve of PDGM moving home health payment away from existing therapy thresholds and toward patient characteristics, they question how the payment overhaul silos musculo-skeletal rehab and neuro rehab. On top of that, they worry that treatment for generalized muscle weakness will fall through the cracks. 

“It leads to the idea that there are only two types of patients who really need rehabilitation,” Langham said. “I don’t like the optics of that. I would go back and then do some of the questionable encounters, the muscle weakness. Generalized muscle weakness is a huge problem.”

Despite the fact that PDGM removes the acceptable codes for documenting generalized muscle weakness, treating the ailment will remain just as important under the new model. Cutting back on treatment could lead to more falls, which could mean more hospitalizations down the road.

The intersection of PDGM and home health therapy isn’t the only place where misconceptions exist. Historically, there have been ample misconceptions around the use of maintenance therapy, as well.

CMS has proposed expanding home health rules to allow therapy assistants to perform maintenance therapy in its proposed payment rule for 2020. Maintenance therapy supports a primary treatment and ensures that a patient’s health status doesn’t decline — and could become an increasingly important tool in delivering outcomes under PDGM.

“I think that people are afraid of it,” Langham said. “If you back to the regulatory language it is a little bit gray and leaves a lot to interpretation. Maintenance is not something we have done a good job of teaching in any of our programs, but it is critical.”

Broadly, this falls in line with the overarching move to streamline care. In April, lawmakers introduced the Home Health Care Planning Improvement Act of 2019 (H.R. 2150) which sought to allow physician assistants, nurse practitioners and other advanced practice nurses to certify home health care services.

Currently, only occupational therapists (OTs), physical therapists (PTs) and speech therapists are allowed to perform maintenance therapy.

“I like maintenance therapy and agree that it is underutilized,” Griffin said. “People with chronic illnesses like [multiple sclerosis] are perfect candidates for maintenance.”

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