PDGM isn’t new—but the rules keep shifting. Learn how top-performing home health agencies are navigating the latest updates in 2026 and where your team may be losing time or revenue.
As a home health and hospice provider, you know that Medicare and Medicaid rules shift annually. One significant shift happened in 2020 when the Center for Medicare and Medicaid Services (CMS) introduced the Patient-Driven Grouping Model (PDGM). This system intended to improve healthcare by focusing payments on patient needs. Instead of basing reimbursement levels on how many times you saw a patient, PDGM relies on their condition.
PDGM also changes annually, which affects how you get paid. Learn what’s new with PDGM in 2026 to stop revenue leaks stemming from non-compliance.
Significant 2026 PDGM Updates include:
Even though the 1.3% rate cut will likely impact your revenues, the cut isn’t as high as originally anticipated. PDGM documentation is essential, since your payments hinge on coding accuracy.
The rules for face-to-face visits changed in 2026. This enables physicians, nurse practitioners, clinical nurse specialists, and physician assistants to meet with patients. This rule can help prevent delays stemming from the old rule, which required the face-to-face visit to be conducted by the certifying physician.
Changes to the Low Payment Utilization Adjustments (LUPA) threshold make it more important to track visits. If you see a patient fewer times than expected in a 30-day period, you could see a large pay cut.
The PDGM compliance tips will help you navigate the changes within your agency:
PDGM home health pay cuts and changes to LUPA thresholds could impact your home health revenue cycles in 2026. If you’re not submitting claims with detailed documentation or if you’re not coding patients properly, you could see your reimbursements plummet. Preparing for these impacts now can save you in the future.
Have new patients and any patients you haven’t seen in six months or longer fill out new paperwork. So, you can verify their insurance coverage and eligibility. Whenever possible, collect a copayment up front. If you need to, discuss copays with patients before scheduling visits.
Hire staff who understand ICD-10 coding to make sure all your patient cases are properly coded, and keep an updated diagnosis and coding manual on hand. If your staff isn’t already familiar with these codes, host a thorough training session.
Host a training session with your clinicians and administrative staff on new case mix loads and LUPA thresholds to help them structure patient visits. Use software that automatically verifies claims before you submit them. Some software can flag missing information, documentation needs, and improper codes. Fix these before sending in a claim.
When you get claim denials from CMS, read the letter carefully and log all the reasons and explanations. If needed, call CMS with questions.
Using a single document management system makes it easier to process denials because of PDPG changes. Quickly access patient notes, wound image captures, physician referrals, emails, and patient communication and send them to CMS to appeal the denial.
WorldVIew’s healthcare solutions let you capture and upload patient data during on-site visits for accurate patient records. Your clinicians aren’t making notes and scrambling to manually enter visit data hours later.
Our wound image management helps you document a patient’s condition, which is heavily considered to determine reimbursement amounts.
Referral AI automatically tracks and routes physician referrals and flags each referral for missing information. If the referral is coming on CMS forms, your team knows to verify patient eligibility up front.
PDGM initially shortened your pay cycle and required extensive documentation. New rules are also cutting your reimbursement levels. Documentation is more crucial now because of case-mix weight changes and comorbidities. You need accurate documents to back up your diagnoses and codes, or risk having CMS reduce your payment.
Home health automations make it easier for your team to adapt:
PDGM was created to improve patient care by focusing on a patient’s condition instead of how many times they visited your agency. But it's complicated and constantly changing. Simple errors can significantly reduce your revenue.
WorldView offers flexible tools to automate procedures and reduce costly data entry errors. Use our tools to speed up intake and verify patient eligibility before starting treatment. Easily attach all required documents to claims before you submit them. Take advantage of our integrations to review claims before you submit.
These changes can shorten your revenue cycles and help you collect costs that better align with your treatments. Schedule a demo today to learn more.