APTA is aware that there may be concerns regarding appropriate use of therapy under PDGM. Per a CMS presentation transcript: "Home Health remains a multi-disciplinary benefit, and payment is bundled to cover all necessary services identified on the individualized Home Health plan of care. So, for example, if a period of care is grouped under the complex nursing interventions group because the primary reason the patient needs Home Health services is for nursing care, therapy services could also be provided if those therapy services are reasonable and necessary and ordered on a Home Health plan of care." See CMS' February 21, 2019 PDGM Presentation Transcript (.pdf). Review all PDPM & PDGM resources.
What You Need to Know
How to Take Action if There Is a Problem
If you are engaged in or have witnessed a billing practice that you think is suspect, consider the following steps:
- Contact the facility's corporate compliance officer or administration point of contact for compliance issues.
- Immediately stop the questionable practice.
- Contact your professional association for guidance.
- When appropriate, consider reporting information to the Office of Inspector General or CMS, particularly if the compliance officer has not responded appropriately.
- Seek knowledgeable legal counsel as appropriate if other efforts are not successful.
The Home Health PDGM, effective January 1, 2020, places a greater reliance on patient characteristics and other information to better align payments with patients' needs. As mandated by the Bipartisan Budget Act of 2018, the unit of payment will switch from 60-day episodes of care to 30-day periods and remove therapy visit thresholds as a determinant of payment. The PDGM will base case-mix adjustment solely on patient characteristics—including timing of episode, admission source, principal diagnosis, functional impairment level, and comorbidities—to place patients into clinically meaningful payment categories.