Home Health Articles and Information


Dec 2, 2019 3:20:00 PM / by Kristi Bajer, BSN, RN, COS-C

PDGM and Therapy Utilization

            “Do the best you can until you know better. Then when you know better, do better.”

                                                        --Maya Angelou 

Has your HHA recognized its therapy utilization is too high to sustain under the PDGM payment model?  You are not alone.  Many HHAs have traditionally let contract or staff therapists dictate therapy visit frequencies.  Now, under PDGM, with no extra therapy reimbursement, HHAs are realizing the utilization practices of the past could no longer be advisable.  These HHAs are often concerned about their risk for audit with behavioral adjustments and may be afraid to change their behavior.

Below are a few tips to make sure your HHAs therapy utilization is managed to meet your patient’s needs based on patient data as well as your HHAs margins.

  • Make sure OASIS functional impairment level and the therapists evaluation agree. Remember, CMS only sees the data from your OASIS NOT the therapy evaluation (unless you are in an audit)
  • Make sure your OASIS functional impairment level (low, medium or high) is used to determine utilization for therapy. High therapy with a documented functional impairment of low doesn’t make sense- and will exceed your payment margin in most cases.
  • Consider higher therapy for those diagnosis groups CMS is calling therapy driven.  MS Rehab and Neuro Rehab
  • Make sure therapists (and everyone else) is practicing to the top of their license. Having another discipline make a visit to complete a task a therapist could have completed could cost your HHA its margin
  • Finally, make sure the director or supervisor is reviewing / auditing all  frequencies- not just therapy.  Ultimately, it is the administrator who is accountable for providing reasonable and necessary care according to the guidelines in the Medicare Benefit Policy Manual


All audits are data driven. Meaning, the data you submit to CMS is used to assess the severity of the illness or injury being treated by your clinical team, determine medical necessity, home bound status, and if the service utilization was appropriate when compared to 7 million plus episodes of care nationwide.

The PDGM payment model is meant to give more guidance clinically and functionally to the HHA caring for the patient under the Medicare home health benefit. If the PDGM has caused your agency to realize therapy utilization may need to be adjusted and you are concerned about triggering an audit, we are happy to run your agency’s data through our ZPIC metrics. If a problem is discovered, OperaCare will work with your HHA to remediate your risk and ensure your success in PDGM.



Tags: PDGM, Compliance, Therapy, Home Health, OASIS

Kristi Bajer, BSN, RN, COS-C

Written by Kristi Bajer, BSN, RN, COS-C

Kristi Bajer BSN, RN, COS-C, brings over 10 years of real world experience as a clinician, director, and administrator in home health. She is a firm believer in diagnosis driven evidence-based care in home health. Currently, she assists agencies with external chart audits and Medicare appeals, as well as providing training and coaching on OperaCare implementation and building QAPI programs using data to drive success and protect agencies from government audits.