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CMS Releases Revised and Additional Instructions for Billing Under PDGM

Posted on Monday, September 9, 2019 11:53 AM

CMS recently released a transmittal revising portions of Chapter 10 of their Claims Processing Manual for implementation of HH PDGM and creates new sections to address them as well.

Of particular interest is Section 10.1.23, Changes in a Beneficiary’s Payment Source.  This section addresses these changes: payment source changes from Medicare Advantage (MA) to original Medicare, payment changes from original Medicare to MA and payment source changes involving Medicaid. 

“Section 80 deals with the HH Grouper program.  The Home Health Resource Group (HHRG) used to pay home health services billed on TOB 032x are determined by the HH Grouper program. HHRGs are represented on claims in the form of HIPPS codes. Like, the HH Pricer, the HH Grouper is a module within Medicare claims processing systems. The HHA sends a HIPPS code on the claim, using revenue code 0023. Medicare systems combine claim data and OASIS data and send the data to the HH Grouper to determine the HIPPS code used for payment. The HIPPS code from the Grouper replaces the provider-submitted HIPPS code on the claim and is then sent to the HH Pricer for payment calculations.

Medicare claims processing systems must send an input record to Grouper for all claims and most adjustments. RAPs and medical review or other program integrity contractor adjustments are not sent to the Grouper. The Grouper will return an output record to the shared systems whenever an input record is sent.”

Source: NAHC Report

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