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
If you have questions about the information in this bulletin, please email [email protected].