652 codes were added, 52 code descriptions were revised and 65 codes were deleted from the 2021 ICD-10-CM code set, effective October 1, 2020 through September 30, 2021.

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PDGM Px Code

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Patient-Driven Groupings Model (PDGM)

Primary (Px)

To use this PDGM Px Code Checker, please copy and paste your code in the box below, and then click on the big blue button that says “Check PDGM” then watch as your code is VALID PDGM Px Code or NOT.
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PDGM stands for ? What is PDGM ? How PDGM Works ?

PDGM stands for Patient-Driven Groupings Model and Px stands for Primary. As the 2020 Home Health Coding Manual went to press, the new home health payment system, the Patient-Driven Groupings Model (PDGM), was set to take effect Jan. 01, 2020. The details of the PDGM system contained in this article are based on the 01/01/20 PPS proposed rule.

The new payment model utilizes 30-day payment periods and stops using the number of therapy visits to determine payment. LUPA thresholds under PDGM will range from two to six visits, depending on the specific HHRG.

CMS will use specific, individual patient characteristics to determine payments in PDGM. The primary diagnosis code on the claim will determine which clinical group the episode falls into.

Once a primary diagnosis grouping is assigned, the classification is further refined by determining the level of care and assistance required by the patient and assigning a functional status of high, medium or low.

The terminology used here has been among the most confusing aspects of the new model, and it is important to note that a functional status of high or low doesn’t refer to the patient’s functional abilities but instead indicates the patient’s level of functional impairment.

It reflects the level of assistance and resource use required for that patient. A high rating means the patient has a high impairment, requires the highest level of care and assistance and is expected to require high use of agency resources.

Additional factors impacting the payment formula include whether the patient is new to home health or has previously received services, and whether the patient was admitted to home health from the community or an institutional setting.

Average resource use by clinical group under PDGM

Among the six clinical groups under the PDGM, Medication management, teaching and assessment(MMTA) has by far the greatest parcent of periods. That's according to an CMS analysis of 2017 Medicare claims data.

Pie Chart of Clinical group and Percent of periods

Coding impacts clinical values

The primary diagnosis code on the claim will determine which of the clinical groups below the episode falls into:

  • Musculoskeletal rehabilitation
  • Neuro/stroke rehabilitation
  • Wound aftercare and skin/non-surgical wound care
  • Behavioral health
  • Complex nursing interventions
  • Medication Management, teaching and assessment (MMTA), which is further subdivided into 7 subgroups:
    1. MMTA - Surgical aftercare
    2. MMTA - Cardiac/circulatory
    3. MMTA - Endocrine
    4. MMTA - GI/GU
    5. MMTA - Infectious disease/neoplasms/blood-forming diseases
    6. MMTA - Respiratory
    7. MMTA - Other

List all diagnoses relevant to the plan of care - not just the six allowed on the OASIS - on the home health claim. In addition to assigning one principal diagnosis, you can assign up to 24 secondary diagnoses, and receive a comorbidity adjustment. A certain combination of secondary diagnoses within designated categories will lead to a comorbidity adjustment. Only one adjustment is applied per episode. Comorbidity adjustments fall into one of three categories: none, low or high. The adjustments are designed to account for the additional resource use required for patients with complex needs.

To qualify for a low comorbidity adjustment, the claim must include one secondary diagnosis found within one of 12 comorbidity subgroups associated with higher resource use. To qualify for a high comorbidity adjustment, the claim must include two 4 or more secondary diagnoses that fall within 34 comorbidity subgroup interactions that account for 18 distinct comorbidity subgroups.

Patients with heart failure and patients with Parkinson's disease are two examples of subgroups that will be eligible for an adjustment.

Avoid listing questionable codes

Under PDGM, failure to use a primary diagnosis code that fits into one of the clinical groups, means you are using a questionable encounter code, which could result in claims getting kicked back to providers, payment delays and potential red flags for auditors.

The red flags would come because if claims are sent back to the agency and then resubmitted with a new primary diagnosis code, it may appear to auditors that the agency isn't confirming the diagnoses with the physician but recoding to resubmit quickly.

Common home health diagnosis codes M62.81 (Muscle weakness (generalized)), R26.89 (Other abnormalities of gait and mobility), M19.91 (Primary osteoarthritis, unspecified site) and R13.10 (Primary osteoarthritis, unspecified site) are among the 20 most common questionable encounter codes under PDGM, according to an analysis from Strategic Healthcare Programs (SHP) in Santa Barbara, Calif.

To avoid these issues, take steps to identify which questionable encounter codes your agency uses and work to gather more detailed information that will lead to more specific, acceptable codes instead.

Top 10 questionable encounter codes in PDGM

Muscle weakness(generalized) was by far the most commonly-used primary diagnosis that would be deemed questionable under the PDGM, according to 2017 data from Santa Barbara, Calif.-based Strategic Healthcare Programs.

Column Chart of Percentage of SOC

Tips to ensure coding accuracy in PDGM

Coding accuracy, specificity and detail will drive the PDGM. Here are a few areas to focus on:

  • Get specific.

    Diagnoses codes that are too vague - meaning the code does not provide adequate information to support the need for home health services - Won't fit into any of the groupings under PDGM. Neither will manifestation codes that are subject to a manifestation/etiology convention and require the etiology code to be reported as the Principal diagnosis.

  • One example of a code that’s too vague: H57.9 (Unspecified disorder of eye and adnexa). You'll also need to watch out for code-first Sequencing conventions such as G99.2 (Myelopathy eases classified elsewhere), and codes that are unlikely to be used in home care or restricted to acute care settings. Note: If you needed another reason to avoid simply copying codes previously used by the hospital or clinic where the patient had an inpatient Stay, this is one.

  • Understand what to do if the primary diagnosis changes.

    Diagnoses codes that are too vague - meaning the code does not provide adequate information to support the need for home health services - Won't fit into any of the groupings under PDGM. Neither will manifestation codes that are subject to a manifestation/etiology convention and require the etiology code to be reported as the Principal diagnosis.

  • Two 30-day payment periods are allowed to have two different case-mix groups to reflect Changes in patient condition, CMS says. However, Similar to PPS, the case mix group cannot be adjusted within each 30-day period.

    If the primary diagnosis changes between the first and second 30-day period, only the claim for the second 30-day period should reflect the new diagnosis. If, for example, the patient suffers a fall before the start of a second, contiguous 30-day period, agencies shouldn’t change the claim for the first 30-day Period.

    CMS explains that the revised Home Health Conditions of Participation (CoPs) already require agencies update the comprehensive assessment if a patient experiences a significant change in condition [§484.55(d)(1) (ii); G546]. In this scenario, a follow-up assessment should be submitted at the start of the second 30-day payment period to reflect the change in functional level. The second 30-day claim would then be grouped into the appropriate case-mix group.

  • Take heed of the process for returning claims.

    CMS clearly outlines the expectation for what will happen when a claim is returned to the provider because it doesn’t have a primary diagnosis that fits into one of the available clinica] groups.

  • CMS notes that updating the primary diagnosis with a more specific or appropriate code would not be considered “up-coding,” as long as there is documentation clearly supporting the need for services and that the physician signs and dates any changes in the plan of care. When a claim is returned for more specific coding. CMS expects the diagnosis on the plan of care to be corrected, too.

  • Know when wound care grouping is appropriate.

    CMS states that for a payment period to be grouped into the wound category, the diagnosis on the claim must reflect a break in skin integrity "for which clinical practice guidelines involve wound care necessitating skilled nursing services."

  • A diagnosis simply indicating infection may or may not demand wound care.