By Celeste Miller, RN, Quality Assurance & Performance Improvement Manager at Signature Healthcare at Home
The Patient-Driven Groupings Model takes effect January 2020. Here are a few ways you can prepare for PDGM with your home health partner.

First things first: 30-day periods

Under PDGM, each 30-day period is grouped into one of 12 clinical groups based on the patient’s principal diagnosis.
The reported principal diagnosis provides information to describe the primary reason patients are receiving home health services under the Medicare home health benefit.
Clinical grouping (under 12 subgroups) is determined by Primary ICD-10 Code:
Clinical Grouping PDGM
PDGM includes a comorbidity adjustment category based on the presence of secondary diagnoses.
Depending on a patient’s secondary diagnoses, a 30-day period may receive no comorbidity adjustment, a low comorbidity adjustment, or a high comorbidity adjustment. Up to 24 secondary diagnoses will be considered in determining the comorbidity adjustment.

  • Low comorbidity adjustment: There is one reported secondary diagnosis that is associated with higher resource use. A 30-day period can have a low comorbidity adjustment or a high comorbidity adjustment, but not both. If a 30-day home health period of care does not have reported comorbidities that fall into one of the adjustments described above, there would be no comorbidity adjustment
  • High comorbidity adjustment: There are two or more secondary diagnoses that are associated with higher resource use when both are reported together compared to if they were reported separately. That is, the two diagnoses may interact with one another, resulting in higher resource use.


Top coding tips under PDGM

Coding is key under PDGM. Here are a few important tips to keep in mind.

  • As a referral source, send your home health partner documentation to support the active diagnosis list.
  • As a referral source, understand which primary diagnosis are not allowed under PDGM.

You don’t have to navigate PDGM alone. Get to know PDGM basics here, and follow us on Facebook for more resources.

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