PDGM Webinar Series
eSolutions, the Medicare billing experts, has joined forces with Karri Wright, Sr. Director of Product Management at Homecare Homebase, to bring you a special webinar series sure to deliver the insights you need to prepare your home health agency for PDGM.
For home health providers, patient intake is a crucial step in the reimbursement process. Onboarding patients, collecting their information and determining what services are needed requires time, efficiency and consistent communication with referral sources. Intake and front-end eligibility lay the foundation for accurate reimbursement and, if it’s done incorrectly, agencies can face delays in payment and major disruptions in their cash flow.
With PDGM starting on January 1, 2020, having an efficient patient intake process is more important than ever. Agencies must adapt to changes like tighter deadlines, more payment groupings and increased claim volume. Having a flawless intake process while taking on these new challenges will make the transition much smoother.
Two things to keep in mind while taking steps toward improving your intake process are referral source and eligibility data.
PDGM will change the way institutional and community referrals affect your agency’s financials. Under PDGM, each 30-day period is classified into one of two admission source categories: community or institutional. The difference lies in what type of healthcare setting a patient stayed in 14 days prior to his or her home health agency (HHA) admission. An institutional referral is when a patient has been discharged from an institutional setting, such as a hospital or skilled nursing facility, in the 14 days before being admitted to an HHA. A community referral is when there is no institutional stay in the 14 days prior to the HHA admission.
In order for the admission source to be coded as institutional, there must be an official admission and discharge from the facility within 14 days prior to the HHA admission. Any 30-day payment period where there was an inpatient admission and discharge (acute hospital) within 14 days prior to the 30-day episode beginning will count as institutional. Only the start of care (SOC) first 30-day payment period can be institutional as a result of a discharge from a post-acute facility. An institutional referral has a higher case mix weight and thus, will pay more than a community referral.
Establishing the accuracy of facility discharges will be critical to ensuring correct home health billing. Educating your staff on the difference between community and institutional referrals will help you get paid correctly the first time. It’s also a good idea to analyze your agency’s historical data to see how you’ll be impacted by PDGM. Looking at your patient population and percentage of past institutional versus community referrals can shed some light on how much this new payment model will affect your revenue cycle.
More than 43,211 diagnoses may be used as a primary diagnosis under PDGM. However, about 40% of the diagnoses allowed for under the current Prospective Payment System (PPS) will not be allowed as primary diagnoses under PDGM, according to Home Health Care News. As an example, the common diagnoses of generalized muscle weakness and generic hypertension will not be accepted once PDGM arrives. It’s critical to educate your coders so they know which primary diagnoses are acceptable under PDGM. CMS offers a list of them on its CY 2020 PDGM Grouper Tool page (Download the file and look for the ICD-10 DXs Excel spreadsheet). Reviewing these codes with your team and comparing them to your frequently billed codes will alleviate stress and help prevent coding errors.
Internal and external communication is also very important. Only physicians can diagnose, so agencies need to communicate with them to make sure they know which diagnosis codes are not acceptable. If unacceptable codes are provided initially, agencies will need to spend additional time working with physicians so they can provide more specific directions for correcting coding so that the HHA can bill appropriately.
Don’t Take on PDGM Alone
PDGM is a major change in the home health industry and is expected to be a resource hog when it goes into effect in January. Instead of stretching your staff thin manually updating eligibility data, consider a service that automates the process.
eSolutions’ best-in-class Medicare Eligibility & Medicare Analytics tools return the most comprehensive, real-time patient data in seconds so you can focus on more important tasks. Our solution shows dates of the most recent inpatient stays, can review diagnosis codes and has the ability to do batch eligibility checks so you can keep up with your entire patient population.