HMH Maestro

Payor Updates

Medicare Changes to Home Health Reimbursement

All Locations

What you need to know

Set to go into effect January 1, 2020, the Patient-Driven Groupings Model (PDGM) is the largest change to the home health reimbursement system in 20 years. It will overhaul how Medicare pays for home health.

PDGM was developed to better align home health reimbursement with patient care needs.

This reimbursement method relies heavily on clinical characteristics and other patient information to create the claim.

PDGM provides an assurance that the clinically complex patient will receive adequate home health care.

How will PDGM affect my as a provider?

What Diagnoses are required for an INITIAL REFERRAL and to develop each PLAN OF CARE?

Additional diagnosis requirements:

What diagnoses will no longer be acceptable under the PDGM model?

Generalized, unspecified symptom codes are no longer acceptable and will no longer qualify a patient for home care services. Instead report the underlying etiology/causation. Examples are:

Additional documentation requirements:

PDGM implementation requires that each diagnosis included on the home health claim be validated or substantiated in writing with supporting documentation. A great deal of information can be obtained in the electronic health record. Each home health referral must include supportive documentation and information to support the required care. Examples are:

Home Health Services

Hackensack Meridian Health At Home
Monmouth and Ocean Counties.

Hackensack Meridian Health JFK At Home
Union, Somerset, and Middlesex Counties.

Visiting Health Services of New Jersey
Passaic, Bergen, and parts of Morris counties.