Patient-Driven Groupings Model (PDGM)
PDGM is Medicare's payment methodology for home health services.
Definition
PDGM is Medicare's payment methodology for home health services. It determines reimbursement based on patient characteristics-including diagnosis, admission source, functional impairment, and comorbidity adjustment-rather than the volume of therapy visits.
Why it matters
PDGM introduced variable LUPA thresholds and changed how agencies manage care planning and reimbursement.
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100 real OASIS scenarios, worked end to end — clinical situation, common mistake, better approach, and key takeaway. Built around OASIS-E2 (effective April 1, 2026) to turn what you assess into accurate, defensible documentation.
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Conversations on lupa & pdgm
Episodes from Inside Home Health that put Patient-Driven Groupings Model (PDGM) in operational context.
Ep 23Ep 23 · Aug 17, 2026
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Ep 24Ep 24 · Sep 16, 2026
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Ep 20Ep 20 · Jul 13, 2026
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Related Blogs
PDGM vs. PPS: What's Changed for Home Health?
PDGM did not replace Medicare's Home Health Prospective Payment System. It changed the case-mix methodology inside HH PPS, and reshaped payment periods, coding, OASIS, LUPA monitoring, billing, and cash flow.
PDGM Documentation Strategies for Home Health Agencies
Under PDGM, documentation establishes the clinical picture that supports classification, medical necessity, coding, and payment. This guide breaks down 15 PDGM documentation strategies, a documentation-to-payment framework, weak-vs-strong examples, and a closed-loop workflow to keep charts consistent and audit-ready.
Unspecified vs. Specified ICD-10 Codes: Key Differences for Home Health
Learn when unspecified ICD-10-CM codes are appropriate, how documented specificity can affect PDGM classification, and how home health agencies can close avoidable coding gaps.
What Is OASIS-E2? A Complete Guide for Home Health Agencies
A practical guide to OASIS-E2: assessment changes, time points, quality and payment uses, EHR and iQIES readiness, and AI support that keeps clinicians in control.
LUPA Explained: How Low Utilization Payment Adjustment Affects Home Health Agencies
LUPA (Low Utilization Payment Adjustment) kicks in when a 30-day home health period falls below its PDGM visit threshold, shifting payment from the case-mix-adjusted 30-day rate to per-visit. This guide explains how thresholds work, what causes avoidable LUPAs, and how to manage LUPA risk without chasing visits.