While the Patient-Driven Groupings Model (PDGM) has been in effect for more than four years, many organizations still struggle to optimize their operations under its guidelines.
To help organizations understand the clinical elements that impact payment under PDGM, 小猪视频 Director of Training and Education Mike Carr, PT, hosted a outlining each of these factors and providing actionable insights and tips for success.
鈥淚t鈥檚 really these five different variables and how they all interact with each other [that determine the reimbursement landscape under PDGM],鈥� Carr explained.
- Clinical Grouping: A patient鈥檚 primary diagnosis determines the clinical category into which they are grouped, which in turn impacts reimbursement. Clinical groups with potentially greater service needs are reimbursed at higher rates to cover the necessary costs.
- Timing: Episode timing under PDGM is classified as early or late, where any care provided after the first 30 days is considered late. The first 30-day period is classified as early and reimbursed at a higher rate due to the patient鈥檚 acuity and anticipated need for increased care.
- Admission Source: Patients admitted from an inpatient stay in an institutional setting, such as a hospital, skilled nursing facility or rehab center, are reimbursed at a higher rate due to their typically greater initial care needs. Those coming from community settings, such as their own home or a referral from a physician鈥檚 office without an inpatient stay, receive a lower rate as their care requirements are generally less intensive at the start. Patients admitted from institutional settings under Medicare Part B as outpatients do not qualify for the higher rate.
- Functional Impairment: Patients with high functional impairment, reflecting difficulties with mobility and self-care, require more intensive care and resources, resulting in higher reimbursement rates. Patients with lower impairment levels receive lower rates, reflecting their less intensive care needs. Functional impairment is the only PDGM variable determined by the OASIS. CMS determines the remaining variables based on claims.
- Comorbidity Scoring: Patients with high comorbidity scores, which are determined by secondary diagnoses on claims, often require more complex and costly care than their healthier counterparts, so reimbursement rates are adjusted upward to meet those increased needs.
Carr encourages organizations to ensure all employees understand how these clinical elements impact reimbursement under PDGM. He highlights the importance of understanding PDGM as the first step in his summary for success.
Summary for PDGM Success
- Understand PDGM
Thriving under PDGM, Carr says, begins with making sure all employees, particularly field staff, have a thorough understanding of PDGM and the elements that impact payment.
鈥淲e can鈥檛 do well with PDGM if we don鈥檛 have a solid understanding of how it all works, why it鈥檚 set up the way it is [and] what goes into the recipe,鈥� Carr said.
Training programs like 小猪视频 Training and Certification+ can aid in staff training processes.
- Plan visits according to reimbursement
Carr asserts visits should be planned according to each patient鈥檚 unique health needs and corresponding reimbursement.
鈥淲e can鈥檛 do the same thing for all patients because they鈥檙e not all the same,鈥� Carr said. 鈥淭hat鈥檚 why our care plan needs to be individualized and our 鈥� visit pattern needs to be individualized specifically to that patient because what worked for one patient may not be the right pattern for the next patient and it also may not fit with the reimbursement that you have.鈥�
- Prevent avoidable LUPAs
Preventing avoidable LUPAs, Carr says, is essential and relatively easy to do.
鈥淭he vast majority of LUPAs can be avoided with appropriate planning,鈥� Carr said. 鈥淚f you鈥檙e having issues with LUPAs, really visit that situation and strategize about, 鈥楬ow can I plan and schedule my visits better or change my care patterns slightly so that I can avoid those LUPAs?鈥欌��
He recommends showing field staff the monetary losses associated with LUPAs and ensuring they know how to address situations where visits must be rescheduled.
鈥淭hings happen but you [shouldn鈥檛] cancel visits,鈥� Carr said. 鈥淵ou [should] reschedule visits to get the same outcomes and get the reimbursement that you deserve.鈥�
- Use technology to achieve success
Carr concluded the session by encouraging organizations to lean on technology to aggregate data and identify processes that require improvement.
鈥淚t鈥檚 getting harder and more complicated every day,鈥� Carr said. 鈥淲e can鈥檛 be too burdensome on ourselves to think that we can keep it straight and our field staff can keep it straight, so really rely on technology and business intelligence kind of tools 鈥� so [you] can spend more time making the changes [you] need to make.鈥�
To watch the full webinar on clinical factors that impact PDGM success, click .
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