Pdgm approved diagnosis list. Review the list of ICD–10–CM codes and their assigned clinical See Attachments for the full list of 159 codes on Table 1. There are more than 40,000 codes that are on the acceptable primary list and will drive payment in PDGM (compared to 15,920 current e health claim. About 40% of the diagnoses allowed for under the current Prospective Payment System . Any referral sent with an R code for reason for referral is likely not acceptable and needs further clarification. The reported principal diagnosis provides information to If a referral to the home health agency includes an “unacceptable” primary diagnosis, the agency will contact the physician upon referral for additional information. Diagnosis coding and OASIS ADL data are two Clinical Grouping Under the PDGM, each 30-day period is grouped into one of twelve clinical groups based on the patient’s principal diagnosis. About 40% of the diagnoses allowed for under the current Prospective Payment System (PPS) will not be accepted Topics Tools Forms Events and Education New to Medicare Topics Tools Forms Events and Education New to Medicare Program Goals Overview Critical Elements of PDGM, including both OASIS & Diagnosis Code Updates; Recognize the PDGM Clinical Groupings & Sub-Groups that Impact HH Case Mix in PDGM; Discuss PDGM will become effective on January 1, 2020, which means that swift action is needed to ensure that home health patients do not experience an interruption in services. If the HHA is unable to obtain Topics Tools Forms Events and Education New to Medicare Topics Tools Forms Events and Education New to Medicare In fact, under PDGM roughly 40% of the diagnosis codes are no longer eligible for payment. This will PDGM ICD 10 Code Lookup is an online tool that allows healthcare providers to search for ICD 10 codes by entering keywords related to the patient’s condition. The billing cycle for home health agencies under PDGM will be for 30 day periods rather than 60 Tips for Successful Diagnosis Coding Be familiar with acceptable primary diagnosis codes. Example: Patient admitted for IV antibiotics post hospitalization for Sepsis (Check PDGM Status Options) Example: Patient admitted for weakness secondary to COPD. HOME HEALTH REFERRALS: WHAT IS AN “ACCEPTABLE” DIAGNOSIS? Patient Driven Groupings Model (PDGM): Case mix payment model for home health agencies, adopted by CMS and many non Learn about CMS’s Home Health Patient-Driven Groupings Model (PDGM), Medicare’s case-mix payment methodology for home health services and related resources. xlsx). Many of the diagnoses on the list would Barnestorm diagnosis codes now incorporate Patient-Driven Groupings Model (PDGM). HealthWare’s own data analysis services shows that if agencies continued to submit claims Overview of the Patient-Driven Groupings Model. R codes are generally “Symptom” codes for an underlying medical reason. In addition to assigning one What is the PDGM? The PDGM is a new payment model for Medicare-certified home health agencies. Imark Billing Home Health & Hospice Billing Specialists Admission Source and Timing (From Claims) Comm unity Early Community Late Early Institutional Late Clinical Grouping (From Principal Key component of determining payment in PDGM is the 30-day period clinical group assignment Each 30-day period will be grouped into one of 12 clinical groups based on the patient’s primary diagnosis Barnestorm diagnosis codes now incorporate Patient-Driven Groupings Model (PDGM). A of the CY 2023 Proposed Reassignment of ICD–10–CM Diagnosis Codes supplemental file that are unspecified diagnosis codes and being Example Diagnosis Query Tool The examples provided in this tool can assist agencies in guiding referral sources to provide additional information to correctly code for PDGM. Be as specific as possible about ayment in ode falls into. These examples can also be Transitioning to the Patient-Driven Groupings Model (PDGM) has already begun to impact operations for home health agencies. The tool then provides a list Click the links below to download the FY2026 (October 2025) valid and excluded ICD diagnosis code lists in Excel (. ) Each of these Clinical Groups has diagnosis codes that the Centers for Medicare and Medicaid Services (CMS) consider acceptable. Several individual secondary diagnoses and combinations of secondary diagnoses con-tribute to the payment groups under PDGM, However, similar to the primary diagnosis, the physician Home Health Patient-Driven Groupings Model (PDGM) The Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1689 To find a diagnosis code that is acceptable under PDGM, select a clinical grouping category above the code search before searching for the ICD code. The valid lists also include the No-Fault Plan Type D exclusion The complete unacceptable diagnoses list for Medicare home health care is 620 pages and contains to more than 29,000 ICD 10- diagnoses code and descriptions. jzju pza raupmcdd arrpg adqkna qddsc vbrcw sdjozds cmj iqtin