What are the 12 clinical groupings in pdgm. Based on the primary diagnosis, a patient can be in 1 of 12 clinical groupings. The PDGM categorizes each period into 432 home health resource groups (HHRGs) based on: What You Should Know About the Patient-Driven Groupings Model for Home Health Services When implemented January 1, 2020, the Patient-Driven Groupings Model (PDGM) adopted by the US Centers for Medicare and Medicaid Services (CMS) will shift home health payment toward a system that focuses on clinical characteristics and other patient information, and away from therapy service visit thresholds . The PDGM relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories and eliminates the use of therapy PDGM Overview PDGM is the current Medicare payment methodology for home health agencies. Ensure Coding Accuracy and Secure Proper Payment Did you know that the codes you assign today will not only affect your agency’s current payment, but will also impact future payments? In fact, many of the new elements in the Patient-Driven Groupings Model (PDGM) payment system were based on coding data that’s being collected NOW! To be a successful coder and make yourself indispensable Oct 23, 2023 · Under PDGM, if four or more items are checked on M1033 (excluding items 8, 9, and 10), the grouper assigns 10 points in addition to points from the other functional domain items for low/medium/high scoring, according to the 2023 home health final rule. The second one is 2KC21. This diagnosis must be a specific ICD-10 code that justifies the need for home health services. There are 12 groups used in PDGM: 4. Comorbidity Adjustment Payments under PDGM are two 30-day payment periods inside of a Apr 5, 2019 · Thresholds for functional levels by clinical group under PDGM - The information below shows the thresholds for patients’ functional levels b Oct 15, 2020 · Under PDGM each of the 432 case-mix groups has a visit threshold ranging from two to six visits to determine whether the period of care meets the LUPA threshold. CMS has mapped specific ICD-10 codes to each clinical grouping. It is the new reimbursement model for Medicare-certified home health patients that will replace the current Prospective Payment System (PPS) model on January 1, 2020. The goal of PDGM is to get organizations to focus more heavily on the clinical characteristics of the patients they are serving and eliminate the use of therapy service Patient-Driven Groupings Model (PDGM) Grouping Tool Help Document Disclaimer: This file was prepared as a service to the public and is not intended to grant rights or impose obligations. Under the HH PDGM, matching a claim to the OASIS assessment is required to process each home health claim. Dec 19, 2025 · 12 Clinical Groupings based on the principle diagnoses reported in each claim. This document outlines what these changes and enhancements are as well as how to setup and use these new features for the PDGM payment model. Clinical Grouping Under the PDGM, each 30-day period is grouped into one of twelve clinical groups based on the patient’s principal diagnosis. These updates help illustrate the evolving landscape of home health care and the data points CMS is considering. Jan 11, 2023 · Second Position Clinical Grouping. It is Mar 19, 2019 · Agencies with low readmission rates and good clinical outcomes can demonstrate very real value. The groups are defined by the principal diagnosis reported on the HH claim. 7% decrease in payments for 2025, or about $280 million aggregate reduction compared to 2024 levels. Neuro/Stroke Rehabilitation 3. K is for the clinical grouping from PDGM (MMTA Infectious Disease). But we know that secondary diagnoses can also impact Home Health resource use and should be taken into account for case-mix adjustment purposes. A key component for calculating payment under PDGM will be clinical group assignment and co-morbidity adjustment, thus making ICD-10 coding more important than ever. The billing cycle for home health agencies under PDGM will be for 30 day periods rather than 60 days. Discuss Required Documentation for PDGM Case Mix Diagnoses. Recognize the PDGM Clinical Groupings & Sub- groups that Impact HH Case Mix in PDGM; Detail the Cardiovascular, Circulatory and Cerebral Subgroups that are Case Mix in PDGM; Apply the New PDGM Case Mix Model with Common Home Health Care Scenarios. PDGM clinical grouping is based on the principal diagnosis reported on the claim and CMS designed the groupings to capture the most common types of care provided. Nov 30, 2024 · In November 2018, CMS finalized a case-mix classification model, the Patient-Driven Groupings Model (PDGM), effective beginning January 1, 2020. Among the subcategories listed above, the impact that the 12 clinical groupings have on the case-mix and how to manage visits per clinical grouping under PDGM. During claims processing, the quality system, known as the Internet Quality Improvement and Evaluation System (iQIES), provides the claims system (FISS), with the OASIS items used for payment grouping under the PDGM. While PDGM is the most significant regulatory and reimbursement reform for home health agencies (HHA) in 20 years, it doesn’t mean therapy practices need to fear it. The points needed to progress between levels will vary based upon the Clinical Grouping. The base payment amount for 2024 is $2,038. These are further categorize Home Health Patient-Driven Groupings Model (PDGM) In November 2018, CMS finalized a new case-mix classification model, the Patient-Driven Groupings Model (PDGM), effective beginning January 1, 2020. Sep 23, 2021 · The Impact of M1033 on PDGM Scoring It is always effective to review some OASIS items that determine functional adjustment level and impact reimbursements. Complex Nursing Interventions Jan 13, 2020 · PDGM Components Timing—Early and Late 30 day payment period Admission Source—Community or Institutional Clinical Grouping from Principal Diagnosis Comorbidity Adjustment—Secondary Diagnoses (up to 24 additional diagnoses) Functional Score (only part of payment equation from OASIS) Jul 30, 2024 · 3. It is Clinical grouping of the primary ICD code is the primary factor that drives the reimbursement rate. 95%) to the CY 2025 home health payment rate to account for the impact of implementing the Patient-Driven Groupings Model (PDGM). Apr 16, 2021 · With PDGM, CMS uses information such as the referral source (institutional or community), episode timing, fall risk, diagnosis coding, comorbidities, and certain OASIS questions to determine the clinical grouping, and thus the reimbursement. Clinical grouping – based on the primary diagnosis from twelve diagnostic categories Functional grouping – based on certain assessment items from a standardized assessment tool that are further categorized as high, medium, or low d with high resource use. Case mix payment groups ical groupings based on the pri-mary diagno is. Nov 20, 2019 · Clinical grouping of the primary ICD code is the primary factor that drives the reimbursement rate. Clinical Grouping Under the PDGM, each 30-day period is grouped into one of twelve clinical groups based on the patient’s principal diagnosis. Reimbursement to the home health agency under PDGM for your ordered services in part is based on assignment to one of 12 clinical groups, which represent the primary reason the patient requires home care. PDGM is designed to more accurately reimburse home health agencies for the services they provide to Medicare beneficiaries. Reimbursement is based on the patient’s characteristics and conditions. The points accumulated from responses to these OASIS items determine if the patient is categorized as having a low, medium, or high functional impairment. The payment under the Patient-Driven Groupings Model (PDGM) for home health services is designed to be more patient-centered and based on a variety of factors, including the patient’s clinical characteristics and needs. It Starts with the Primary Diagnosis The determinate of a patient’s clinical grouping is based solely on their primary diagnosis. These groups align with the most common types of care provided in home health care. HHA Owners need to take a hard look at the competence bar of its clinical staff and determine what adjustments, if any, are nec-essary Functional and Clinical Updates The proposed rule includes several functional and clinical updates that provide a look at the changes in the distribution of care periods by the twelve clinical groupings. Under the Patient-Driven Groupings Model Jan 21, 2025 · Master PDGM reimbursement with expert coding strategies, clinical grouping insights, and comorbidity optimization tips for home health agencies. Mar 12, 2020 · There has been a lot of concern about understanding PDGM (Patient-Driven Groupings Model) and how it affects your billing procedures. Nov 18, 2024 · The Patient-Driven Groupings Model represents a transformative change in home health reimbursement, shifting focus from service volume to patient characteristics and care needs. Payment groupings: PDGM will increase the number of payment groupings and unique case-mix potential from 153 to 432. Community - A 30 day period of care is considered Institutional if the patient had an acute care stay within 14 days of home care admission. Wounds: Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care 4. PPS allowed for 153 combinations, but with PDGM each 30-day period can be categorized into one of 432 case-mix groups. Then we faced a pandemic and it was all hands-on deck understandably. 2 Under PDGM, if the LUPA threshold is met, the 30-day period of care shall be reimbursed at the full 30-day national, standardized payment amount. PDGM Final Rule: • 30-day periods are grouped into 12 clinical groups based on principle diagnosis Clinical grouping of the primary ICD code is the primary factor that drives the reimbursement rate. Apr 14, 2025 · The Patient Driven Groupings Model (PDGM), implemented by CMS on January 1, 2020, marked a historic shift in how Medicare reimburses home health services. It is not intended to be used to determine partial payments or outliers. The PDGM Clinical Groupings Based off Primary Diagnosis on Claim! This is a way to capture the common types of care provided and more accurately align payments with the costs of providing care → Resource Use. 12, R13. Admission Source and Episode Timing 2. The model is a case mix model that groups patients for payment purposes into categories based on certain patient characteristics. Diagnosis coding and OASIS ADL data are two significant areas that the agency can impact by gaining a deeper understanding of both items. Let’s look at how accurate diagnosis coding affects your reimbursement. The Patient Driven Groupings Model (PDGM) — Overview The PDGM is a new payment model for Medicare certified home health agencies (HHAs). This cheat sheet describes the groupings under PDGM and expected reimbursement for each group with important tips on coding to ensure accurate reimbursement. Reasons why episodes can’t be assigned to a clinical group are either because the primary diagnosis code was (a) Non-specific, (b) Unlikely The Patient Driven Groupings Model (PDGM) — Overview The PDGM is a new payment model for Medicare certifed home health agencies (HHAs). Patient-Driven Groupings Model -Functional Level Scoring Being reimbursed for the work your agency has provided is critical to growth and success. PDGM: Clinical Groups Cheat Sheet Clinical groups is an important aspect of the establishment of the Medicare home health patient’s reimbursement under Patient Driven Groupings Model (PDGM). Sep 4, 2019 · Factoring in Admission Source & Referral Timing Beyond the minimum payment for a clinical grouping, the next factor affecting reiumbursement is the admission source and timing of the referral. This is the reason referrals from institutional settings are paid at a higher rate For additional information, refer to the February 12, 2019, Home Health Patient-Driven Groupings Model National Provider Call CMS presentation and transcript on the CMS Home Health Patient-Driven Groupings Model web page on the CMS website. ICD-10-CM coding will be the ONLY source of determining clinical grouping. 11, R13. The reported principal diagnosis provides information to describe the primary reason for which patients are receiving home health services under the Medicare home health benefit. Diagnosis coding and OASIS ADL data are two significant areas that the agency can impact by deeper education and understanding of both items. By using the right codes, healthcare providers can ensure accurate payments, compliance with CMS guidelines, and improved patient outcomes. Each 30-day period is grouped into one of 12 clinical categories based on the patient’s main diagnosis. It Starts with the Primary Diagnosis The determinate of a patient’s clinical grouping is based solely on their primary ical groupings based on the pri-mary diagno is. Patient-Driven Groupings Model (PDGM) The complexity of the new CMS Patient-Driven Groupings Model (PDGM) for home health care agencies requires significant planning to ensure that your organization has sustainable strategies in 2020 and beyond. Jan 16, 2020 · Clinical grouping Under PDGM, patients are categorized into 12 clinical groups based solely on the primary diagnosis code reported on the Medicare claim. Key changes include the transition from 60-day to 30-day payment periods, elimination of therapy visit thresholds for payments, and a comprehensive adjustment mechanism based on comorbidity. The more risk factors present, the higher the likelihood of hospitalization, which can impact both patient outcomes and agency performance under the Patient-Driven Groupings Model (PDGM). It Starts with the Primary Diagnosis The determinate of a patient’s clinical grouping is based solely on their primary Reimbursement to the home health agency under PDGM for your ordered services in part is based on assignment to one of 12 clinical groups, which represent the primary reason the patient requires home care. WHAT IS PDGM? The Patient Driven Groupings Model is a case-mix classification model for home health organizations. Review PDGM information now to prepare for your future. By promoting accurate, patient-centered payments, PDGM has the potential to improve care quality while controlling costs. Clinical Group: Clinical groups are intended to reflect the primary reason for a patient receiving home health services. A successor of the proposed Home Health Groupings Model (HHGM), PDGM introduces new payment episode timings and removes Program Goals Overview Critical Elements of PDGM, including both OASIS & Diagnosis Code Updates; Recognize the PDGM Clinical Groupings & Sub-Groups that Impact HH Case Mix in PDGM; Discuss Challenges and Requirements for Precise Coding in PDGM. It evaluates a patient’s risk for hospitalization based on a variety of clinical and behavioral indicators. Aug 21, 2019 · February 12, 2019, Overview of the Patient-Driven Groupings Model (PDGM) presentation Audio Recording Transcript MM11577 – Manual Updates Related to Calendar Year (CY) 2020 Home Health Payment Policy Changes, Maintenance Therapy, and Remote Patient Monitoring SE20005 – The Role of Therapy under the Home Health Patient-Driven Groupings Model Jan 11, 2023 · If it were only that easy. Visit the CMS Home Health Patient-Driven Groupings Model webpage for PDGM resources. Jul 30, 2024 · Transitioning to the Patient-Driven Groupings Model (PDGM) has already begun to impact operations for home health agencies. Apr 5, 2019 · Thresholds for functional levels by clinical group under PDGM - The information below shows the thresholds for patients’ functional levels b Feb 12, 2019 · The principal diagnosis reported on Home Health claims determines the clinical group under the PDGM. In the final rule, CMS projected a 1. The financial and operational impact of denials and extrapolation risk. Clinicians must understand 12 clinical groupings If the primary diagnosis does not fit into one of the 12 clinical groups in the payment model, this is considered an "Unaccepted Diagnosis" May 3, 2022 · Among the subcategories listed above, it is important for home health organizations to understand the impact that the 12 clinical groupings have on the case-mix and how to manage visits per clinical grouping under PDGM. A detailed description of each of the case-mix variables The document outlines the Patient-Driven Groupings Model (PDGM) introduced at the 2018 leadership conference, detailing its implementation timeline and major changes to home health payment structures. There are 432 clinical groupings. CMS set up PDGM with financial incentives for providers to begin treating patients with more acute care needs first. Jan 30, 2026 · Therefore, the following R-codes will be assigned to the Neuro Rehab clinical group: R13. CMS uses a home health case-mix system, the Patient-Driven Groupings Model (PDGM), to adjust payment for differences in patient characteristics (Figure 2). 3rd Position is Functional Level. 13, R13. This grouping directly affects how Medicare reimburses home health Oct 15, 2020 · Under PDGM each of the 432 case-mix groups has a visit threshold ranging from two to six visits to determine whether the period of care meets the LUPA threshold. Not all diagnoses are included in the PDGM. 6. Within that Jun 29, 2021 · Example: Under the home health Patient-Driven Groupings Model (PDGM) a home health period of care for March 29 to April 27 was submitted with a skilled nursing visit dated April 28 (see the boxed in revenue line in the screenprint below), which falls outside of the “FROM” and “TO” date on the claim. 19 – Multiple Dysphagia codes b) S and T codes – There are many of the S and T codes where the fracture and/or injury is unspecified, but the site is specified, which CMS maintains should be identified. PDGM is a new payment model for the Home Health Prospective Payment System (HH PPS) Relies on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories, and Eliminates the use of therapy service thresholds Program Goals Overview Critical Elements of PDGM, including both OASIS & Diagnosis Code Updates; Recognize the PDGM Clinical Groupings & Sub-Groups that Impact HH Case Mix in PDGM; Discuss Challenges and Requirements for Precise Coding in PDGM. May 12, 2023 · PDGM ICD 10 Code Lookup is a tool that healthcare providers can use to ensure that they are using the correct ICD 10 codes for billing and payment under the new Patient-Driven Groupings Model. The 12 groupings have separate groupings for the functional score previously mentioned. PDGM’s value-focus re-quires that three of the four groups are assess-ment and diagnosis related. 10, R13. 13. Mar 21, 2025 · Clinical Grouping in PDGM ( Patient Driven Grouping Model): The PDGM classifies each 30-day period of care by principal diagnosis into one of 12 clinical groups or subgroups: 1. As one of the most significant updates to PPS since 2000, the CMS approach to the Patient-Driven Groupings Model (PDGM) focuses on providing a higher quality of care, keeping individuals in the best acuity setting possible and reducing unnecessary treatment and services. Admission Source - Institutional vs. PDGM 2022 Many agencies felt like they were ready for PDGM in 2020. Real-life examples of audit findings from HealthRev Partners’ data analytics insights. Maximize your revenue today. Designed to improve payment accuracy and reduce incentives for volume-based care, PDGM replaced the long-standing Prospective Payment System (PPS), introducing a case-mix adjusted 30-day payment period, new clinical groupings, and a renewed Topics Tools Forms Events and Education New to Medicare Topics Tools Forms Events and Education New to Medicare The Clinical Grouping variable is a key component of the PDGM, determined by the patient’s primary diagnosis. PDGM Visit Utilization Best Practices using Episode Management Strategies PDGM periods show overutilization and under-utilization of visits In this world of the Patient-Driven Groupings Model (PDGM), home health providers are becoming accustomed to dealing with the 60-day episode of care as two 30-day billing periods. Learn how clinical groupings and comorbidity will be affected. The PDGM, or Home Health PPS Grouper Software (HHGS), relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories and eliminates the use of therapy service Accurate, patient-specific coding is imperative to success with the Patient-Driven Groupings Model or PDGM. These certain primary diagnoses are known as “questionable encounters” (QE’s). These are further categorize May 3, 2022 · Among the subcategories listed above, it is important for home health organizations to understand the impact that the 12 clinical groupings have on the case-mix and how to manage visits per clinical grouping under PDGM. PDGM Clinical Grouping Based on the primary diagnosis reported on the claim, the patient will be grouped into one of twelve clinical groups. They are general groupings and are in the graphic below. 3. Transitioning to the Patient-Driven Groupings Model (PDGM) has already begun to impact operations for home health agencies that are indeed convinced that preparation must begin now. Key Risk Factors Assessed in M1033 Patient Name must exactly match the information submitted on the claim, including suffix if applicable. Vague, ill-defined, or symptom diagnoses cannot be reported as the principal diagnosis under the PDGM. PDGM has four fundamental reimbursement components: 1. Mar 22, 2022 · Clinical Group: The primary reason the patient requires home care, represented by 12 distinct clinical groups as determined by the principal diagnosis reported on the home health claim; Sep 19, 2007 · As the implementation of PDGM begins to edge closer, there is rising concern and tension around the submission of claims that contain primary diagnoses that do not fall into one of the twelve clinical groupings established by CMS. 2. Top reasons for Additional Documentation Requests (ADRs) in home health. b) Clinical competence. Notice, MMTA has several sub groups. With options from twelve Clinical Groupings, three Impairment levels and three co-morbidity assessments, clinical ac-curacy is critical. Jan 1, 2020 · WHAT PROVIDERS NEED TO KNOW ABOUT PDGM PDGM stands for Patient-Driven Groupings Model. CMS priorities in 2026: PDGM trends, LUPA behavior, and clinical groupings under review. These are further categoriz Jul 22, 2022 · The Patient-Driven Groupings Model or PDGM drastically changed how Medicare pays for Home Health. Learn about PDGM and how it pays for HH. Selecting the right ICD-10 code will become especially important since in the current PPS model, 19% of the 30-day periods would be considered Questionable Encounters (QE) in the new PDGM. different PDGM payment groups by regressing resource use for each of the five categories (admission source, timing, clinical grouping, functional impairment level, and comorbidity adjustment) using a fixed effects model. By ensuring your diagnosis coding is correct, you will ensure proper payment while addressing the clinical needs of your patients. Take Aways Understanding What Is HHRG In Medicare? The Home Health Resource Group, or HHRG, is a critical component in the Medicare payment system for home health care providers. Functional Impairment Level 4. A diagnosis is not assigned to one of the 12 clinical groups in the payment model if i “Unacceptable” diagnoses are those diagnoses that the federal government has deter-mined are not appropriate or Medicare coverage of home health services. The primary diagnosis must have one of twelve PDGM classifications according to home health care coding guidelines. 4th Position is for Comorbidity adjustment- 1, meaning low. Musculoskeletal Rehabilitation 2. PDGM calculations are very complex. It functions as a classification system that groups patients according to their clinical conditions, functional abilities, and service utilization patterns. Of the more than 70,000 ICD-10-CM diagnosis Codes, about 43,000 have PDGM classifications and can be used as a primary diagnosis. The patient has at least 1 comorbidity that increases reimbursement. Case mix payment groups Jun 1, 2025 · In November 2018, CMS finalized a case-mix classification model, the Patient-Driven Groupings Model (PDGM), effective beginning January 1, 2020. The May 14, 2019 · Under PDGM, each 30-day period of care is assigned to one of 12 clinical groupings, each of which has its own base payment rate adjustment. Once assigned a clinical grouping, OASIS is used to determine functional level, then comorbidity adjustment. PDGM HHRG STRUCTURE Admission Status and Episode Timing Community Early Community Institutional Institutional Late Early Late Clinical Groupings (From Primary Diagnosis on claim) MMTA Surgical Aftercare MMTA MMTA MMTA MMTA MMTA Patient-Driven Groupings Model (PDGM) Grouping Tool Help Document Disclaimer: This file was prepared as a service to the public and is not intended to grant rights or impose obligations. The model took effect January 1, 2020 and is the largest change to the reimbursement system in nearly 20 years. A is for low. Questionable encounter codes are described as being “too vague,” meaning the Under the HH PDGM, matching a claim to the OASIS assessment is required to process each home health claim. The reimbursement calculation is very complicated. The 12 clinical groups include: Musculoskeletal rehabilitation Neuro-stroke rehabilitation Wound care Behavioral healthcare Complex nursing interventions MMTA aftercare MMTA cardiac/circulatory Aug 21, 2019 · February 12, 2019, Overview of the Patient-Driven Groupings Model (PDGM) presentation Audio Recording Transcript MM11577 – Manual Updates Related to Calendar Year (CY) 2020 Home Health Payment Policy Changes, Maintenance Therapy, and Remote Patient Monitoring SE20005 – The Role of Therapy under the Home Health Patient-Driven Groupings Model Feb 12, 2019 · Patient-Driven Groupings Model (PDGM) The PDGM is a new payment model for the Home Health Prospective Payment System (HH PPS) that relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories and eliminates the use of therapy service thresholds. 14 & R13. 975% (half of the calculated permanent adjustment of -3. Complex Nursing Interventions Patient Driven Groupings Model (PDGM) Overview Modifications and enhancements have been made to myUnity to comply with the CMS PDGM regulation effective 1/1/2020. This rule finalizes a permanent prospective adjustment of -1. The PDGM, or Home Health PPS Grouper Software (HHGS), relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories and eliminates the use of therapy service Mar 21, 2025 · Clinical Grouping in PDGM ( Patient Driven Grouping Model): The PDGM classifies each 30-day period of care by principal diagnosis into one of 12 clinical groups or subgroups: 1. Sep 19, 2022 · What are the 12 clinical groupings in PDGM? 9/19/2022 by Keith Grunig What are the 12 clinical groupings in PDGM? Here's an expanded graphic that shows what the primary reason to provide home health encounters. The information provided is only intended for use as a learning tool for determining the HIPPS codes assigned to 30-day periods. The primary diagnosis must have a Patient Driven Groupings Model (PDGM) classification. Clinical Grouping 3. jtpfcw wzsc yiqihp hbksiww ctvt vtucgxpc pwuvqhu rqfi clfiy zwdmoxp