Understanding PDGM Billing and Coding Changes: How Outsourcing Can Be the Solution

Big changes are on the horizon for home health agencies (HHA) in 2020. Patient-Driven Grouping Models, or PDGM, goes into effect beginning on January 1, 2020, radically changing the ways in which HHAs are reimbursed for services for Medicare beneficiaries. PDGM is an effort by the Centers for Medicare & Medicaid Services (CMS) to reduce the cost of home health care and shift from volume-driven, or a fee-for-service model, to value-driven care. Under the value-driven care model, HHAs and other care providers are rewarded for helping clients improve their health, especially those individuals with chronic health conditions. CMS believes this shift will lead to better care for patients, improved health care for communities, and an overall reduction in health care costs.


Impact on HHAs

For HHAs, the shift to PDGM is monumental. While it certainly impacts the ways in which care plans are developed and implemented, it also has a significant impact on the ways in which services are billed and reimbursed.


A few of the most significant changes include:

  • Shift from a 60-day episode to a 30-day episode
  • Case-mix groupings will increase to 432 combinations from the current 153
  • Changes in allowable primary diagnoses
  • Outcome and Assessment Information Set (OASIS) will be categorized into five subcategories
  • Low Utilization Payment Adjustment (LUPA) will be paid on a per-visit basis at national per-visit rates

For HHA owners who are focused on delivering exceptional client care, getting up to speed (and staying up to speed) on the new coding and billing requirements for PDGM in order to ensure timely reimbursement, is nothing short of a monumental task. That’s why partnering with an industry leader such as Dominion Revenue Solutions, that understands the complexity of health care reimbursement, is the right choice for HHAs.


Outsourcing Billing Is a Smart Business Decision

Time and money spent on training to understand the new coding requirements for billing and reimbursement under PDGM is time and money taken away from client care and caregiver professional development.


Dominion Revenue Solutions is backed by more than 20 years of hands-on experience in the home health industry. We understand the importance of revenue billing and revenue cycle management for the long-term business health of HHAs. That’s why our staff is dedicated to maintaining cutting-edge industry knowledge about PDGM and a wide range of multiple-payer situations, including traditional Medicare, Medicare Managed Care, private insurance, Medicaid, Medicare Secondary Payer, workers’ compensation plans, VA & Tricare.


Our comprehensive revenue cycle management program includes:

  • Patient eligibility checks
  • Alert for change in insurance within episode
  • Medical billing
  • Claims transmission and tracking until payment is received
  • Payment posting
  • Appeals and denial management
  • Monthly financial reports (with explanation for any reversals)
  • Bi-annual episodical reports
  • And so much more


In addition, with our commitment to exceptional customer service, we match each client with a dedicated and experienced billing associate who has the expertise to ensure their organization stays compliant with governments regulations and guidelines. Our goal is to help you feel confident in your partnership with Dominion Revenue Solutions every step of the way so that you can channel your passion for delivering home health care to clients and making real, impactful differences in their lives.


Contact Us to Learn More

Learn more about how Dominion Revenue Solutions is prepared to help clients meet the challenges of PDGM. Dominion Revenue Solutions is the right choice for outsourcing billing and revenue cycle management, contact us today at 888-471-9333.


Let us show you how our comprehensive service offerings and our knowledgeable team of experts can help maximize revenue, leading to more efficient management of your agency, ultimately enabling improved patient care.