No News Isn’t Good News with PDGM

The Patient Driven Groupings Model outlined in the 2019 proposed PPS rule has a lot in common with the Home Health Groupings Model (HHGM) proposed, but not finalized in last year’s PPS rule. [CPH, 12/16]

But where the HHGM gave details about which codes would be deemed questionable encounters, PDGM doesn’t offer specifics.

When used to identify the primary reason for care, questionable encounter codes “were too vague, meaning the code did not provide adequate information to support the need for home health services,” the 2018 proposed PPS rule states.

If HHGM had been finalized, agencies submitting claims with these questionable encounter codes as the primary diagnosis would find their claims returned to the provider, the 2018 proposed rule states.

But CMS didn’t specify questionable encounters or associated questionable encounter codes in the 2019 proposed rule, instead only providing 38,409 primary diagnosis codes that drive clinical groups under PDGM.

Under HHGM, 38,408 codes were acceptable and 26,268 were questionable. A DecisionHealth analysis found that only eight codes deemed questionable under HHGM are listed as codes that fit into a clinical group under PDGM.

To reduce confusion, CMS intentionally left information on questionable encounter codes out of the 2019 proposed rule and associated tools, a CMS spokesperson tells DecisionHealth.

CMS received feedback last year indicating some agencies “were confused and thought a code on that list would mean that the patient was not eligible for home health care,” the CMS spokesperson says. “We do not want [agencies] to have that same impression this year.”

But the absence of this information leaves industry experts wondering what will happen under PDGM.