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CMS Issues Instructions for PDGM Claims Processing

Posted on Saturday, February 16, 2019 2:33 PM

CMS has issued Change Request 11081, which provides claim processing instructions to the Medicare Administrative Contractors (MACs) that will be necessary to process home health claims with the implementation of the Patient Driven Groupings Model.

The PDGM will assign 30-day periods of care into one of 432 case-mix groups based on the following variables:

  • Timing: The first 30-day period of care is an early period of care. The second or later 30-day period of care is a late period of care;
  • Admission Source: If the patient was referred to home health from the community or an acute or post-acute care referral source;
  • Clinical Group: The primary reason the patient requires home care, represented by distinct clinical groups as determined by the principal diagnosis reported on the home health claim;
  • Functional Impairment Level: The patient’s functional impairment level is based on Outcome and Assessment Information Set (OASIS) items for activities of daily living; and
  • Comorbidity Adjustment: If the patient has certain comorbid conditions reported on the home health claim, the 30-day period of care can receive a no, low, or high comorbidity adjustment.
  • In conjunction with the PDGM, there is a change to the Low-Utilization Payment Adjustment (LUPA) threshold from the current four or fewer visits per 60-day episode of care to thresholds that vary based on the 10th percentile of visits in a 30-day period of care for each case-mix group in the PDGM.

Finally, beginning in CY 2020, newly enrolled HHAs on or after January 1, 2019 will no longer receive split-percentage payments. HHAs that are certified for participation in Medicare effective on or after January 1, 2019, will be required to submit a “no pay” RAP at the beginning of care to establish the home health period of care, as well as, every 30 days thereafter upon implementation of the PDGM in CY 2020. Existing HHAs will continue to receive RAP payments upon implementation of the PDGM in CY 2020. For split percentage payments to be made, existing HHAs would have to submit a RAP at the beginning of each 30-day period of care. For the first 30-day period of care, the split percentage payment would be 60/40 and all subsequent 30-day periods of care would be a split percentage payment of 50/50.

Source: NAHC Report

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