PDGM Tip and Information Guide

Understanding PDGM

Timing - PDGM splits each 60-day certification into two separate 30-day payment periods. 

Early (days 1–30) and Late (days 31–60) — each billed and scored independently.

Admission Source - Every episode is classified as either Community (referred from home, physician office, or outpatient setting) or Institutional (referred from a hospital, SNF, IRF, or LTCH).

Institutional sources carry a higher payment rate. 

Clinical Groupings - The principal ICD-10 diagnosis at SOC or ROC determines which of the ten clinical groupings the episode falls into — and the grouping directly drives the case-mix weight and payment rate. 

Functional Impairment - Functional impairment is scored Low, Medium, or High based on specific OASIS-E items at SOC/ROC 

Comorbidity Adjustments - PDGM applies a comorbidity adjustment — None, Low, or High — based on secondary ICD-10 diagnoses, with High producing the greatest payment increase. 

OASIS-E2 - Questions affecting PDGM - The OASIS-E is a precision clinical document, not a checkbox exercise — its accuracy directly determines your PDGM case-mix group. Key items to assess carefully:

M1033 (hospitalization risk) – Signs and symptoms characterizing the patient’s risk for hospitalization. Assessed at SOC, ROC, and Follow-up (REC)... See full article.