Rethinking PDGM Changes: Gold Mine or Land Mine?


Joe Osentoski, BAS, RN-BC

ADR and Appeals Specialist

Gateway Home Health Coding & Consulting LLC


A recent Home Health Care News article was an interview with April Anthony, CEO of Encompass Health’s home health and hospice business.

https://homehealthcarenews.com/2020/01/encompass-healths-april-anthony-knee-jerk-therapy-reactions-may-prove-costly/

It addressed many of the actions taken by Encompass to prepare for the now-implemented Patient-Driven Groupings Model (PDGM). Two items in particular warrant further comment.


First is the use of concurrent visits, called “team admissions”, when admitting a patient with both nursing and therapy services ordered. One advantage stated is that both clinicians can obtain the patient’s health history at the same time and absolve the patient from having to repeat this information if nursing and therapy did separate assessments. Another is that this makes the clinicians “far more efficient” in the admission process and developing a care plan.


One focus area under PDGM is that eight functional OASIS items (M1033; M1800, 1820, 1830, 1840, 1850, 1860) generate the Functional Impairment Level score for payment. By using the team admission process with both clinicians being present it will generate an “appropriate functional assessment” since this should foster correct OASIS scoring and reduce conflicting assessments between disciplines.

At face value and as an example of rethinking how care is provided under PDGM this is a laudable effort. But despite the claims that doing team admissions has improved employee satisfaction, patient satisfaction, and obtained better outcomes, there are some risks to this strategy.


While Medicare allows multiple clinicians to visit a patient at the same time, this refers to two individuals being needed to provide the service. CMS further states that despite two individuals being present if only one is needed to provide the required care then only one visit may be covered. Herein lays the rub of “team admissions.”


CMS specifically states from Internet-Only Manual (IOM), Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7, Section 70.2B (70.2 - Counting Visits Under the Hospital and Medical Plans (Rev. 208, Issued: 04-22-15, Effective: 01-01-15, Implementation: 05-11-15) that “Generally, one visit may be covered each time an HHA [home health agency] employee, or someone providing home health services under arrangements with the HHA, enters the patient's home and provides a covered service to a patient who meets the criteria in §30 [section 30]…If two individuals are present, but only one is needed to provide the care, only one visit may be covered…”


There is an exception for home health agencies furnishing outpatient services with a facility under arrangement, but that does not pertain to provision of home health service. So CMS does not provide routine coverage for two clinicians making concurrent visits. This is because both disciplines cannot be realistically said to be providing service at the same time. The Home Health Conditions of Participation require that nursing complete the OASIS Assessment except for cases when only therapy service is ordered.

(See 42 CFR 484.55(a): Comprehensive assessment of patients https://www.law.cornell.edu/cfr/text/42/484.55)


If the therapy clinician shows earlier visit times than the nurse, any medical reviewer or careful surveyor may determine that the correct order of assessment completion has not been met. Apart from the demographic information being obtained that is common to both nursing and therapy, just what each discipline is doing while the other is conducting assessment functions is unclear. Collaboration on developing a plan of care may be accomplished by many other communication methods other than both being on-site at the same time, and then run no risk of overlapping service.


Also, unless an agency has a different process for admissions of Medicare Advantage (MA) patients, any of the (MA) payers using a contract reviewer may deny the services if there is ANY overlap of times between disciplines. These contract reviewers have previously proven to be especially adept and zealous in denying claims based on overlapping visits. And since these reviews primarily occur on a post payment basis, the risk of using this practice on MA claims may not be known for a long period of time.

The second item warranting comment is the use of “pre-coding” of claims. This is viewed to be a “simple” tip that promotes alignment between the physician record, the hospital record and the home health record. As with “team assessments,” the use of pre-coding raises some compliance questions.


Most important to these is how the diagnoses relevant to home health service, that will be part of the plan of care and the focus of care, can be determined without seeing the patient. Of course, there is information in the referral documents and content from the physician record, but these are most often full of diagnoses that are combination of history, current, or acute issues.


Tasking the clinician with validating pre-coded diagnoses and conditions, instead of completing the assessment and identifying the focus of care, risks a removal of the coding and plan of care from actual clinician findings. At time of admission the key document(s) in this entire process is the physician face-to-face encounter that MUST be shown to be “related to the primary reason the patient requires home health services” (IOM Pub. 100-02, Chapter 7, Section 30.5.1). If pre-coding points in a different direction than the face-to-face encounter indicates, the outcome will be non-affirmation if under Review Choice Demonstration pre-claim review, or denial in case of any medical review.


The issue is not that the clinician seeing the patient needs to be a certified coding specialist. Moreover, the clinician in the field needs to be a home health care compliant charting specialist. This includes knowledge of what Medicare requires and a clear determination of the current and acute issues that home health will actually address, including the diagnoses and conditions that will affect and direct generation of the plan of care. Coding should come after--and not pre-determine how--these diagnoses and conditions are determined.


Clinician and agency knowledge of the requirement that the physician face-to-face encounter, OASIS assessment findings, and plan of care align is the key to the smooth plan of care generation with accurate coding that PDGM requires. Since coding is now a key factor in generating PDGM payment (via the Principal Diagnosis Reported on Claim and the Comorbidity Adjustment), it is now fair game for all types of medical review to deny claims, whether via Medicare Administrative Contractor Targeted Probe and Educate (TPE) or Unified Program Integrity Contractor (UPIC) audits.


A valid home health admission and diagnosis coding process requires that the patient be seen by the clinician to validate the physician referral for home health need. Otherwise it would be like having a physician face-to-face encounter without the physician actually seeing the patient.


In conclusion, PDGM does require a rethinking of how home health care is delivered. This includes a thorough assessment of agency referral, admission, care provision, coding, and billing processes. But in making changes there remains a need to maintain compliance with CMS’ requirements, lest the agency later find out that this “gold mine” of new practices later turn into a “land mine” of denied payments.

©2019 BY GATEWAY HOME HEALTH CODING AND CONSULTING, LLC

  • Facebook Social Icon
  • Twitter Social Icon
  • LinkedIn Social Icon