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Patient-Driven Groupings Model: Therapy Then and Now

April 16, 2020
Documentation, Billing, & Coding By Armi Hernandez, Consultant

The Bipartisan Budget Act of 2018 (BBA of 2018), House Resolution (HR) 1892, that was passed by Congress in February 2018, precipitated modifications to the Medicare program. One of the modifications is the reimbursement reform of the Home Health Prospective Payment System (HH PPS). Effective January 1, 2020, the Patient-Driven Groupings Model (PDGM) was implemented by the Centers for Medicare & Medicaid Services (CMS). According to CMS, PDGM focuses on each patient's clinical characteristics and other information by placing respective care into an appropriate category. This eliminates the use of therapy visit thresholds as the basis for reimbursement.

therapy in HH


Does This Mean That Therapy is No Longer Needed?

Do not confuse the reimbursement methodology with the Home Health (HH) Medicare eligibility and coverage requirements. Those are not the same. Yes, the payment calculation for HH providers has changed; however, the criteria for receiving HH services did not change. The HH skilled services are Nursing, Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP), social services (SS), and HH aides. Before PDGM, providing the therapy visit threshold meant that the HH base rate for the 60-day episode of care increased as well. The HH providers and therapists have paid close attention to the number of visits, as this was the basis for the reimbursement calculation. The implementation of PDGM does not eliminate therapy services when the patient has a need for therapy. The new requirements emphasize that the patient's clinical presentation is the basis for the reimbursement methodology.

Why Is Therapy Needed?

The importance of therapy under PDGM did not change. The therapist should know the reason for the therapy referral. The assessment will identify the inability of the patient to perform specific functional tasks caused by the recent illness or injury. The medical record must include the reason for the therapy referral. The therapist must identify the functional limitation(s) using functional tests and measures and the benefit of skilled therapy intervention. The therapy plan of care (POC) for services will be developed to meet the needs of the patient. This will be incorporated into the overall plans and goals for the interdisciplinary team. The documentation must demonstrate reasonable and necessary care.

How Can Therapy Be Provided?

There is no one size fits all approach. In that respect, there should not be a standardized frequency and duration of treatment. Each therapist (PT, OT, or SLP) should determine the number of therapy visits and the length of care based on the individual needs of the patient, following the initial evaluation. Involving the patient, the family or caregivers in the development of the POC also promotes patient-centered care. Accepted standards of practice support the services rendered under the physician's orders and demonstrate cohesion with the interdisciplinary team’s plan. The therapist's documentation should reinforce the need for appropriate and necessary treatment irrespective of a targeted number of therapy visits.

What Is The Value of Therapy?

As part of the interdisciplinary team, therapy is integral in enhancing the patient’s safe mobility, functional abilities, and physical activity in the home environment and the community, resulting in quality of life. A patient’s well-being also decreases the risk of rehospitalization.  

Having the expertise of the therapist in determining the functional abilities of the patient ensures accurate reporting of the Outcome and Assessment Information Set (OASIS). The purpose of the OASIS data items is to measure patient outcomes and to improve HH care. The data is included in the Home Health Compare website for consumers to check and compare the quality of care of HH agencies. This website also provides the following information: the services offered by the HH agency (nursing, PT, OT, SLP, SS, and HH aides); the quality of care information known as Quality Measures; and the Quality of Patient Care Star Rating which is the performance of each HH agency compared to their peers. Providing quality care, with the right quantity of therapy services, will produce exceptional patient outcomes. Both patients and their family members will recognize outcomes. This will help achieve commendable patient satisfaction and excellent quality scores.

Let us not lose sight of the relevance of the therapists in HH. What sets therapists apart are the unique and distinct skills to address the functional limitations caused by the medical condition. Therapists can turn disability into ability. Changes in health care are constant; what must not change is the provision in delivering reasonable and necessary services.

For more information, contact Deborah Alexander at 717-213-3122 or email

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