The Centers for Medicare and Medicaid Services (CMS) use the Patient-Driven Groupings Model (PDGM) payment methodology to reimburse home health agencies that provide home health services to Medicare beneficiaries under Medicare fee-for-service. As a reminder, PDGM has been in effect since January 1, 2020. CHPW is updating this bulletin to ensure new providers or billers are aware of this methodology.
Highlights of the PDGM include:
- An increased reliance on clinical characteristics and other patient information helps ensure “meaningful payment categories” for home health periods of care.
- The home health unit of payment has a 30-day period of care.
- The 30-day periods are assigned to one of 432 case-mix groups based on specific variables including (but not limited to) admission source, functional impairment level, etc.
- Home infusion therapy payment rates are updated routinely.
- Therapy service thresholds were eliminated.
- Therapy assistants are allowed to provide maintenance therapy.
CHPW follows the CMS Medicare methodology; therefore, all such services for CHPW Medicare Advantage members should be billed according to the PDGM.
Please refer to the following CMS resources for an overview of the PDGM:
- Home Health Patient-Driven Groupings Model
- Centers for Medicare & Medicaid Services Patient-Driven Groupings Model
Questions?
If you have questions about the information in this bulletin, please email [email protected].
What kind of care do you need? Not every medical issue needs emergency care. If you have a medical issue that doesn’t seem to be life-threatening, but you’re not sure what to do, see if your local Community Health Center clinic or primary care doctor offers virtual care. If they do, they will tell you how to set up your virtual care appointment.
