Debunking Common PDGM Primary Diagnosis Myths

In order for home health providers to see reimbursement success, they need to be able to separate myths from facts when it comes to the Patient-Driven Groupings Model (PDGM).

But one specific point of confusion has been primary diagnosis clinical groups.

“There are a lot of rumors and myths floating around out there,” Robbi D. Funderburk James, coding and OASIS manager at BlackTree Healthcare Consulting, said during a Tuesday webinar. “I see a lot of times that we are interacting with our coders, our physicians and maybe causing frustrations all the way around.”


Overall, there are 12 primary diagnosis clinical groups under PDGM.

One popular myth is that all unspecified codes are unacceptable PDGM primary codes. On the contrary, there are many unspecified codes that are acceptable to bill as PDGM primary and fall into a clinical diagnosis group.

Some examples of this are CHF unspecified, AFib unspecified and COPD unspecified.


“What is true about unacceptable codes under PDGM is that if you have an unspecified anatomical location on the body or unspecified laterality. Those codes will typically not bill under PDGM,” James said. “What CMS is saying is that if we have an arm fracture, in order to appropriately treat this, we would need to know whether the fracture is the right arm or left. CMS requires the physician to state that. It can’t be clinician observed.”

Another myth that has gained traction is that all R codes, more commonly known as symptom codes, are unacceptable primary codes.

Unlike the last myth, this one is mostly true with one exception, according to James.

“The exception to that is the R.13.1 Dysphagia codes,” she said. “In our final rule in 2020, CMS agreed with those in our industry who spoke up and said [that] we must treat dysphagia and we can’t always wait for there to be a confirmed etiology. We need to be able to do that in a timely fashion to prevent subsequent harm to the patient.”

Another myth that frequently pops up has to do with codes that are unacceptable as primary diagnoses also being unacceptable as co-morbidity diagnoses. In actuality, codes that are unacceptable as primary are acceptable co-morbidity codes.

Still, James urges providers to seek greater specificity from physicians when the circumstances call for it.

“This doesn’t mean that in some instances, we shouldn’t take the time to query our physicians to get more specificity and laterality,” she said. “We definitely want to do those things when it is appropriate and necessary, but if you are unable to, it’s not going to hold your claim up.”

Moving forward, there are a number of measures providers can take to make sure they are getting into the appropriate PDGM primary categories, including building a strong referral and intake department.

“It’s all going to start with your referral team and intake team at your agency level,” James said. “We want to make sure that our referral team has good relationships with our referral sources, and that they take the opportunities to educate their referral sources and the providers on what it is we’re going to need as home health agencies to bill under PDGM.”

Knowing when it is and isn’t necessary to query — and training clinical staff to know, too — is also key.

“There are going to be times when we’re going to need field clinicians to follow up on diagnoses, especially those instances where they find a diagnosis in the home that wasn’t mentioned anywhere on the intake and referral paperwork,” James said.

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