PDGM: Better Information & Better Care

VNSNY: Your Trusted Partner in Home Health Care is Now Your Go-To Resource for Patient-Driven Groupings Model (PDGM)

On January 1, 2020, the Centers for Medicare and Medicaid Services (CMS) rolled out a new system for home health care referral reimbursement called PDGM. The main change for you is in the information required to refer patients for home health care.

Below we list new information requirements under PDGM.

Just as you’ve trusted VNSNY to deliver exceptional home health care for your most medically complex patients for over 125 years, you can count on us as your partner for guidance on PDGM. Our goal is to ensure that your patients receive the care they need, when they need it, for the best possible outcomes.


What Is PDGM?

PDGM (Patient-Driven Groupings Model) is a new value-based payment model used by Medicare and other payers to reimburse certified home health care agencies. It took effect January 1, 2020.

  • Patient-Driven refers to a focus on patient needs and characteristics.
  • Groupings refers to the use of diagnoses and other characteristics to assign patients to clinical groups that match clinical complexity with level of care.

A value-based system like PDGM places an emphasis on cost and quality of care: how much value will a patient get from a given service. This is why demonstrating a patient’s primary and secondary diagnoses, as well as comorbidities, is so important under PDGM.

PDGM places greater emphasis on clinical complexity and comorbidities—a core competency for VNSNY.


A Snapshot of the New PDGM Requirements

With PDGM, CMS has raised the bar on the information needed for home health care referrals. Better information equals better care. Evidence has shown that accurately capturing your patient’s clinical complexity under a system such as PDGM may help to reduce ED visits and rehospitalizations and increase patient satisfaction.

Under PDGM, the following is needed for referrals to VNSNY:

  • Information on discharge from a hospital or nursing facility in the past 14 days, including name of facility, discharge date, and whether it was an inpatient, ED, or observation visit
  • Physician-signed orders (either EMR or VNSNY’s new universal Referral Form), including a Face-to-Face Encounter Form with date of encounter (not date of referral)
  • Detailed information on primary and secondary diagnoses, including
    • Medical history related to primary diagnosis
    • Relevant comorbidities or secondary diagnoses that affect plan of care
    • Body part, laterality, and underlying cause of symptoms
  • Note that under PDGM, CMS no longer accepts symptoms (such as weakness, gait abnormality, or debility) in place of specific diagnoses. Also, certain diagnoses that you may have used in the past for referrals will no longer be accepted by CMS under the new system. Consulting with VNSNY at the time of referral can help ensure that an accepted diagnosis is selected and that patients are appropriately assigned to clinical guidelines.

Starting on January 1, 2020, for referrals that do not meet PDGM requirements, VNSNY may have to contact your office to verify information.


We’ll help you get PDGM referrals right the first time

Have a question about PDGM? Give us a call or schedule a consult with your VNSNY account representative. We’ll walk you and your staff through the steps for making successful referrals and avoid potential delays in referrals. We can also conduct team workshop trainings.

Your VNSNY account representative will provide you with a PDGM Referral Toolkit that includes:

  • Referral Checklist
  • PDGM Referral Form
  • Detailed examples about CMS-eligible diagnoses, including how to identify ineligible ones and how to correct them

Questions about PDGM? Call VNSNY today.