For home health agency leaders, one of the biggest challenges of the Patient-Driven Groupings Model (PDGM) is submitting claims with primary diagnoses that don’t fit into one of the 12 clinical groupings. Many industry professionals refer to this as the “questionable encounter” issue.
Under PDGM, claims for questionable encounters will be sent back to the agency as “returned to provider” (RTP). An RTP is not denial of payment, but rather an opportunity to review and resubmit a claim with more a appropriate, and still justified, primary diagnosis that does fit into a clinical grouping.
Documenting symptom codes that do not fit into a PDGM clinical grouping is a common mistake that can be considered a questionable encounter. The good news is that commonly used symptom codes can very frequently be associated with a more specific condition. Coding guidance dictates that when a symptom is being treated, if the symptom is related to a more specific diagnosis, then the more specific diagnosis should be coded.
Agencies can minimize questionable encounters using these best-practice strategies:
- Work with your referral source to make sure the more specific condition for the symptom code is included on the referral. For example, imagine you’re caring for a patient with osteoarthritis in their legs who is presenting with a gait abnormality. Instead of coding the gait abnormality, your agency should consider coding the osteoarthritis because it is the source of the gait abnormality.
- Work with your intake team to ensure they can recognize codes that are not associated with a clinical grouping. Be ready to ask your referral source for a more specific diagnosis.
- Work with your clinical team to make sure that when their treatment is directed at a symptom, clinicians are documenting the original source of that symptom.
Keep in mind this guidance from CMS:
CMS has stated that there will still be episodes that don’t fit into a clinical grouping. Agencies must know that CMS will associate any diagnoses that don’t fit into a clinical grouping with conditions not normally associated with skilled need. It’s also important to remember that PDGM does not change the home health benefit or the Conditions of Participation (CoPs). If none of the above strategies lead to a more appropriate primary diagnosis, the agency should carefully consider whether or not the clinical presentation of that patient justifies skilled intervention from a home health team. This is the agency’s acknowledgement of the regulation in the home health benefit.
CMS will likely be monitoring responses from agencies very closely, and they may flag agencies if suspected of either accepting or declining patients based on payment opportunities. Following the best practices above is an ethical approach to addressing primary diagnoses in PDGM that will keep agencies successful and compliant.