The Home Health industry is looking toward significant changes on January 1, 2020 related to the Medicare reimbursement and payment. The industry will transition to a Patient Driven Grouper Model (PDGM) which will require a greater focus and importance on the Primary Diagnosis. The Primary Diagnosis will be a key factor in determining home health reimbursement as well as patient care and services.  

Starting in 2020 this model of payment will not accept 40% of the Diagnoses that are currently being used as the Primary diagnosis. These are mainly symptom codes that do not give enough specificity as to the reason for the need for home health services. Studies show that 15% of current home health claims will not be in compliance in 2020 due to unacceptable Primary diagnoses, the number one Diagnosis used being Weakness M62.81.

Examples of these diagnoses that will not be accepted as the primary diagnosis include:

M62.81 Muscle Weakness

R26.89 Other abnormality of gait

R26.81 Unsteadiness of feet

R29.6 Repeated falls

R53.1 Weakness

R33.9 Retention of urine

Dysphagia, unspec.

M25.561/M25.562 Pain in right/left knee

M25.551/M25.552 Pain in right/left hip

M54.9 Dorsalgia, unspec.

M25.511/M25.512 Pain in right/left shoulder

M54.5 Low back pain

M19.90 Unspecified Osteoarthritis, unspecified site

M19.91 Primary Osteoarthritis, unspecified site

S72.001D Fracture of unspecified part of Rt femur

S72.002D Fracture of unspecified part of Left femur

In an effort to make sure all of our patients have Primary diagnoses that are acceptable to this new payment model by 2020, the Home Care & Hospice Alliance of Maine is sharing this information to alert Physicians and referral sources of this significant change.  Please assist home care and hospice providers transition to this new model by starting now to make sure all patients needing home health will have a specific Diagnosis rather than one that only identifies a symptom.

The care of our patients is always our top priority and we hope the implementation of this new model will only help us improve the services that we provide.

Thank you for your referrals to home care and hospice. 

Laurie Belden, Executive Director

Home Care & Hospice Alliance of Maine