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2023 PDGM Utilization for Congestive Heart Failure

Posted by Melissa Cott on Apr 16, 2023

There are thirty-six (36) different casemix scenarios for cardiac patients under Medicare's Patient-Driven-Groupings- Model (PDGM) payment system (new rates effective January 1, 2023). The casemix is contingent on from where the patient was discharged, her/his functional abilities, risk factors, and the number of additional relevant diagnoses (co-morbidities).

The presence of risk factors increases the need for visits. If there are few risk factors, less visits should be made. Download the Patient Teaching Plan for  Congestive Heart FailureLikewise, the more risk factors, the more visits.

The reimbursement for cardiac patients under 2023 PDGM is $996 to $2818.

Why this should be a 30-day episode.

  • The patient has a teachable daytime caregiver OR
  • The patient does not have a teachable caregiver but is alert and oriented…

This is most likely a 30-day episode if the patient has a competent, teachable caregiver. The focus of nursing visits is to assure that the physician’s medical careplan for CHF is working, and the medical careplan for co-morbidities is also working. The patient/caregiver can be taught symptom monitoring. 

How many visits does it take to assure that the physician’s careplan is effective? 

Depending on the number of problems the patient has, if she has a teachable caregiver, the physician's careplan for cardiac and co-morbidity symptom control should be achieved in 2-3 weeks. The 2023 PDGM Medicare average number of nursing visits (no therapy visits) is about 13 for this episode. Of course this is adjusted based on the number of patient risk factors.

Why this should be a 60-day episode.

  • The patient does not have a teachable daytime caregiver AND is confused OR
  • The patient’s prior self care and/or mobility status is WORSE now than before admission…

What was the patient’s functional ability prior to this episode?

If the patient’s mobility or self-care condition is the SAME as it was prior to this episode, physical and occupational therapy is not indicated. However if the patient's condition is the SAME and patient has NO DAYTIME CAREGIVER to assist with ambulation or self-care, and clinical documentation indicates she will decline without therapeutic intervention, s/he may be entitled to MAINTENANCE therapy.  Additionally, if PT or OT will be provided, a home health aide is also indicated...since...the patient has no daytime caregiver but has functional deficits.

The 2023 PDGM Medicare average number of therapy visits for is about 7 for a 30-day episode for the patient also receiving nursing.

Average 2023 PDGM Utilization for Cardiac Monitoring

The average 30-day 2023 PDGM reimbursement for cardiac monitoring is $2015. The average number of visits for a 30-day episode is 7 therapy and 6 skilled nursing. If the patient does not need therapy, the nurse should make 10-13 visits. Of course if the patient achieves clinical stability (and - if indicated - functional stability) in less visits the patient can be discharged sooner. This visit schedule will keep you consistent with expected utilization under 2023 PDGM, and, with solid documentation, help you avoid an audit or ADR (Additional Document Review).

Best Practice Assessment Strategies for Congestive Heart Failure (CHF) 

  • Monitor vital signs; auscultate breath sounds, noting crackles, wheezes. Note presence of dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, persistent cough.
  • Assess for edema: measure abdominal girth, distended neck and peripheral vessels.
  • Document cardiopulmonary response to activity. Note tachycardia, dysrhythmias, dyspnea, diaphoresis, pallor.
  • Record weight daily.
  • Recommend: changing position frequently; elevating feet when sitting. Encourage active and passive exercises. Increase activity as tolerated.
  • Investigate reports of sudden extreme dyspnea and air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom.

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