Preparing for PDGM: Changes and Implications for Home Health Billing

Are you ready for the changes coming your way? Brace yourself, because PDGM is about to shake up home health billing.

Get prepared and stay ahead of the game with our comprehensive guide. Discover key changes that will directly impact your reimbursement.

Uncover the implications of PDGM on home health services. And most importantly, learn essential strategies and best practices to ensure successful billing under this new system.

Don’t get left behind – read on to master PDGM billing.

Overview of PDGM

PDGM is a new payment model that will greatly impact home health billing. The PDGM implementation timeline is set to begin on January 1, 2020. This means that home health agencies need to start preparing for the changes now in order to ensure a smooth transition.

The impact on home health agencies will be significant, as PDGM introduces major changes in how payments are calculated and reimbursed. Under the new model, payments will be based on patient characteristics rather than therapy visits, which may require agencies to adjust their staffing and care delivery strategies.

Additionally, PDGM includes several other changes such as the elimination of therapy thresholds and the introduction of more comprehensive assessments. It is crucial for agencies to understand these changes and adapt their billing processes accordingly to avoid any disruptions in cash flow.

Key Changes in Home Health Billing Under PDGM

Get ready for a shift in how you bill for home health services with these key updates.

Under PDGM, there are significant changes that will impact your revenue and bring new coding challenges. Here’s what you need to know:

  • Payment Categories: PDGM replaces the existing 60-day episode payment model with 30-day periods, resulting in more frequent billing cycles.
  • Clinical Groupings: The new system classifies patients into one of twelve clinical groups based on their primary reason for home health care. Accurate coding is crucial to ensure proper reimbursement.
  • Comorbidity Adjustments: PDGM introduces comorbidity adjustments that account for the complexity of patient conditions. Proper documentation and coding of comorbidities are essential to maximize revenue.

With these updates, your billing processes must adapt to meet the requirements of PDGM and navigate potential revenue impacts and coding challenges successfully.

Stay informed, train your staff, and prepare ahead to ensure a smooth transition.

Implications of PDGM on Reimbursement for Home Health Services

The shift to PDGM will have a significant impact on how reimbursement for home health services is calculated and received. Under this new payment model, agencies will face various reimbursement challenges that can have a substantial financial impact.

One major change is the shift from 60-day episodes of care to 30-day periods. This means that agencies will need to closely monitor patient outcomes and ensure efficient utilization of resources within each shorter period.

Additionally, PDGM incorporates a case-mix adjustment methodology based on patient characteristics and clinical needs, which could lead to variations in reimbursement rates. Agencies must carefully assess their documentation processes and coding accuracy to accurately capture patient complexity and secure appropriate reimbursement levels.

Furthermore, the elimination of therapy thresholds may affect financial stability for agencies heavily reliant on therapy services as a revenue source. It is crucial for agencies to proactively prepare for these changes to mitigate potential financial challenges under the new reimbursement system.

Strategies for Successful Billing and Coding Under PDGM

One effective strategy for successful billing and coding under PDGM is to ensure accurate documentation of patient complexity and clinical needs. This helps you capture the appropriate level of reimbursement and avoid any coding challenges that may arise.

To optimize your billing process, consider the following:

  • Regularly review and update your coding guidelines: Stay up-to-date with the latest coding rules and regulations to ensure accurate documentation.
  • Improve communication with clinicians: Foster a collaborative relationship with your clinical staff to enhance understanding of patient complexities, resulting in more precise coding.
  • Implement regular audits: Conduct routine audits of your coding practices to identify any areas for improvement and ensure compliance.

Best Practices for Ensuring Compliance With PDGM Requirements

To ensure compliance with PDGM requirements, it’s important to regularly train and educate your staff on the latest coding guidelines and regulations.

Documentation requirements play a crucial role in accurately coding home health services. Make sure your staff understands the specific information that needs to be documented for each visit, including the patient’s condition, treatment provided, and any changes in care plan. Emphasize the importance of thorough and detailed documentation to support accurate coding.

In addition to documentation requirements, coding accuracy is another key aspect of PDGM compliance. Train your staff on proper coding techniques and review their work regularly to identify any areas for improvement.


In conclusion, preparing for PDGM is crucial for home health billing professionals. The key changes in billing under PDGM will significantly impact reimbursement for home health services. It is important to implement strategies and best practices to ensure successful billing and coding under PDGM while also ensuring compliance with its requirements.

One interesting statistic to highlight the implications of PDGM is that according to a study, 65% of home health agencies expect a decrease in reimbursement rates due to the new payment model. This visual representation emphasizes the importance of being proactive in adapting to these changes.

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