Maximizing Your Revenue Under PDGM
Understanding how Medicare calculates your payment is the first step toward maximizing your reimbursement. As explained in this video, Medicare uses a formula based on the patient’s clinical characteristics and other data to place each 30-day period of care into a payment group.
This Patient-Driven Groupings Model (PDGM) formula includes five key categories that impact your payment:
- Admission Source
- Timing
- Clinical Grouping
- Functional Impairment Level
- Comorbidity Adjustment
Accurate coding and classification in each of these categories can significantly affect your revenue. The tools below are designed to help you understand and optimize your PDGM payments.
Patient-Driven Groupings Model Formula
PDGM ICD Lookup Tool
Ensure your primary diagnosis code is valid.
There are over 43,000+ primary Dx codes—but only those on CMS’s approved list will be accepted. Use this tool to confirm your primary diagnosis is billable.
PDGM Comorbidity Adjustment Tool
Check for comorbidity codes that may increase payment.
Secondary diagnosis codes can affect your plan of care and potentially increase payment by up to 20%. Use this tool to see if your comorbidity qualifies for an adjustment.
PDGM LUPA Lookup Tool
Avoid unnecessary payment reductions.
Determine the visit threshold for your 30-day period of care. This tool helps you avoid a LUPA adjustment when more visits are clinically appropriate.
What data source was used: HH PPS Grouper Software HH PDGM v05.1.24 posted on 8/13/2024.
The use of this tool does not replace clinical judgment. Providers should use their professional expertise and discretion when determining appropriate codes, and sequencing of codes. ICD-10 codes and guidelines may change over time. Users should regularly consult the official ICD-10 resources to stay informed of any updates.
This tool is not intended for direct use in billing. Users must consult official billing guidelines and policies before submission.
This tool is designed to align with current PDGM regulations. However, users are responsible for ensuring compliance with all applicable federal, state, and local laws.
The creators of this tool accept no liability for any errors or omissions in the information provided. Users are encouraged to seek professional advice when necessary.