The Role of Therapy Under PDGM

CMS has published MLN Matters® SE20005: The Role of Therapy under the Home Health Patient-Driven Groupings Model (PDGM) to provide information on the continuing role of therapy under the PDGM, emphasizing that even though therapy thresholds were eliminated for case-mix adjustment under the PDGM, “The need for therapy services under the 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 under the 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.