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June 30, 2020

The Role of Therapy under the Home Health Patient-Driven Groupings Model (PDGM)

The Centers for Medicare & Medicaid Services (CMS) has published MLN SE20005External PDF (PDF, 94.01 KB) to provide information on the continuing role of therapy under the Patient-Driven Groupings Model (PDGM), emphasizing that though therapy thresholds were eliminated for case-mix adjustment under the PDGM. "The need for therapy services under PDGM remains unchanged. Therapy provision should be determined by the individual needs of the patient without restriction on the types of disciplines provided or the frequency or duration of visits."

Medicare home health case-mixes the under PDGM were created considering past trends of therapy usage. If, therapy thresholds unexpectedly change, CMS will revise case mixes that may potentially result in decreased reimbursement. Home Health Agencies should not turn away patient referrals or limit therapy services based on reimbursement. This is not a responsible patient care option. As long as the individual meets the criteria for home health services as described in the regulations at 42 CFR 409.42, the individual can receive Medicare home health services, including therapy services.

For more information please review MLN SE20005, "The Role of Therapy under the Home Health Patient-Driven Groupings Model (PDGM)External PDF" (PDF, 94.01 KB).

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