Why Home Health Providers Will Need to ‘Spoon-Feed’ Physicians Under PDGM

The home health industry is right on the cusp of the Patient-Driven Groupings Model (PDGM) becoming the new normal.

Among its changes, the payment overhaul gets rid of scores of previously acceptable primary diagnosis codes under the Prospective Payment System (PPS). In fact, PDGM has roughly 40% fewer acceptable codes compared to the current payment model, which has been in place for about 20 decades.

When most people think about PDGM, however, they automatically turn their attention to therapy changes, the new 30-day billing periods and the model’s now 4.36% behavioral adjustment. Those issues are important, but agencies can’t afford to neglect the sometimes under-the-radar questionable encounter topic.


To get ahead of PDGM, home health agencies will need to be proactive about educating coders — and the physician community as well.

“Take [the Excel spreadsheet in the PDGM Grouper Tool CY 2019] to whoever is doing your coding and tell them, ‘Do not, as of today, send me one more plan of care or one more OASIS or one more claim that has a primary diagnosis that is not on this list,’” Melinda Gaboury, co-founder and CEO of Healthcare Provider Solutions Inc., said in March during an industry event.

Founded in 2001, Healthcare Provider Solutions Inc. is a Nashville, Tennessee-based consulting firm that serves the home health and hospice industries.


Broadly, some say primary diagnosis changes may even impact conversations between home health agencies and physicians, who will have to rethink how, when and why they refer patients to home health in some cases.

Dr. William Rhoades, a geriatrician at Advocate Lutheran General Hospital, discussed the topic Wednesday during the Private Duty Symposium in Naperville, Illinois. The symposium was hosted by the Illinois HomeCare & Hospice Council, Leading Age Illinois and the Illinois Chapter of the Home Care Association of America.

The geriatrician actually touched on the topic via personal experience.

When Dr. Rhoades’s mother-in-law was returning home from the hospital, he had to arrange for home health care to aide her. His mother-in-law needed physical therapy (PT), so he made a referral and created a home health care note based on his assessment of her, citing weakness, gait disorder and pneumonia.

Later, Dr. Rhoades was informed by the home health agency that they could not send someone out to the home for “weakness.”

“My nurse called up the home health agency, and they said, ‘Dr. Rhoades’s note is wrong. We need him to amend it because we can’t go out,’” he said. “I called them up and asked how to amend it. They said my diagnosis doesn’t cover [home health] anymore. I asked, ‘What diagnosis will cover [this under home health] and got zero answers.”

Advocate Lutheran General Hospital is a Park Ridge, Illinois-based non-profit teaching hospital, and a member of Advocate Health Care, Illinois’ largest health care system.

In total, PDGM has 432 case-mix groups determined by timing, clinical grouping, admission source, functional impairment and co-morbidity adjustment. Claims with primary diagnoses that don’t fall under one of PDGM’s 12 clinical groupings are questionable encounters.

Generalized muscle weakness is a common example of a questionable encounter. Instead of using generalized muscle weakness, providers need to look beyond that trait for the root cause, such as musculoskeletal disorder, stroke or brain injury.

Dr. Rhoades urges home health agencies to tell physicians which diagnosis will allow their patients to receive home health care after a referral is rejected.

“The person talking to the doctors has to have the answer … that’s what [home health] needs to do. The person taking the referral, give us the diagnosis, spoon-feed us what we need to do — because that’s what’s causing the world of stress for physicians,” he said.

While it’s true home health providers will have to educate the physician community, some agency owners worry about overstepping their authority.

In fact, one industry source at Wednesday’s event told Home Health Care News that he worried “spoon-feeding” physicians could lead to unwanted attention from federal watchdogs and compliance enforcers.

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