PDGM 30-Day Groupings

By Sharon Litwin January 10, 2020

30-day periods are placed into different subgroups for each of the following five categories:

1. Admission source (two subgroups):
• Community or
• Institutional admission source

2. Timing of the 30-day period (two subgroups):
• Early (first 30-day period) or
• Late (every subsequent payment period after the first period)

3. Clinical Grouping – 12 groups based on Primary Diagnosis Only
• Musculoskeletal Rehabilitation
• Neuro/Stroke Rehabilitation
• Wounds
• Behavioral Health Care
• Complex Nursing Interventions
• MMTA – Surgical Aftercare
• MMTA – Cardiac and Circulatory
• MMTA – Endocrine
• MMTA – Gastrointestinal Tract and Genitourinary System
• MMTA – Infectious Disease, Neoplasms, and Blood-Forming Diseases
• MMTA – Respiratory
• MMTA- Other

*Note – MMTA is Medication Management, Teaching and Assessment

4. Functional Impairment Level (3 subgroups)
Low, Medium, or High-based on the OASIS responses to:
• M1800 – grooming
• M1810 – upper body dressing
• M1820 – lower body dressing
• M1830 – bathing
• M1840 – toilet transferring
• M1850 – transferring
• M1860 – ambulation/locomotion
• M1033 – hospitalization risk – *excluding responses 8-reports exhaustion, 9-risk(s) not listed in 1-8, and 10-none of the above

5. Comorbidity Adjustment
• From Secondary Diagnosis Reported on Claims
o None
o Low
o High

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PDGM Diagnosis Coding

By Sharon M. Litwin, January 10, 2020


As discussed in the Home Health PDGM overview, diagnosis coding is a major factor, contributing solely to the Clinical Group and the Comorbidity Adjustment. The coding rules are so complex already under ICD-10, and now with PDGM, there are many more items to take into consideration.

This chapter will deep dive into HH Diagnosis coding under PDGM.

For a review, the Patient Driven Groupings Model (PDGM) went into effect on January 1, 2020. PDGM will require that 30-day periods are used for billing, rather than 60 days. The initial payment, RAP, will be reduced from 60% or (50%) to 20%, and there will be 432 HHRG’s versus 153 under PPS. The Clinical episode of care, including the Plan of Care, will remain at 60 days, causing considerable confusion since 30- day payment periods are occurring within the 60 days and stand alone. Is PDGM rocket science? Well, I tend to think that this is a very complex system where a lot of ongoing education is needed until one can really understand all the facets.

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Sharon Litwin answers agency questions about clinical documentation improvement

Following a recent DecisionHealth webinar about creating a concurrent review process and improving clinical documentation ahead of the Patient-Driven Groupings Model (PDGM), agencies asked questions of Sharon Litwin, founder and senior managing partner at 5 Star Consultants in Camdenton, Mo. Click here to see!

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Sharon Litwin answers agency questions about clinical documentation improvement

PDGM Part 2 – How Will You Deal with PDGM?

With trying to prepare for the changes that will be brought about by PDGM, do you wonder if you have the right teams in place? With adequate staffing for patient care playing such a large role in our day-to-day operational success, can you imagine not having the right staff to effectively code and review your Medicare episodes, the bread and butter to our companies?
Staff turnover, absenteeism and lack of HH qualified candidates trained in coding and OASIS-D can result in losses of thousands in dollars before you know it. Complicate that with 30-day periods that will be coming with PDGM and it could result in a financial disaster.
The real scenario of how you will be spending your time:
• Insuring staff complete accurate and timely documentation for our 30-day billing.
• Trying to hire HH qualified staff. All too often we see RN’s who come to homecare fresh from the Hospital or SNF with little understanding on how skilled care is provided in the home, HH documentation and how to apply OASIS guidelines to the assessments they perform.
• And to rub more salt in the wound, what about when preceptors training your new staff have not been properly evaluated or trained themselves? Probably because they have only been with you for 6 months and they had to “learn by doing” and the one they learned from was already mentally out the door and could only talk about “why they are leaving”.
• Not to mention you had to eliminate that supervisor position due to financial metrics and you don’t have that person overseeing your episodes anymore?
• Oh, yes, you have assigned it to that one remaining Clinical Manager, and she can do it . . . RIGHT? With all of the other duties she has been assigned to do, please don’t count on it.
• People will typically only do what they feel they can humanly do. It is called self -regulating. It is a common theme in homecare. We think because we have assigned it to someone, they will do it. No, they won’t! They will put it on top of their already full plate, and something will get buried underneath it.

Don’t let that be your coding and OASIS review.
In a time when some agencies will not be able to count on the ready cash flow that your 60 Day episode RAP payment helped with, it will be leaner times for many agencies looking forward to RAP payments on a 30-Day period. There will be pressure on the agencies to “create efficient strategies”, (also known as downsizing) to improve company metrics. Your Coding and Functional scoring will play a large role in your episodic payments. Why trust it in this stressful environment to in house personnel who really do not fully understand the impact PDGM will play?
Consider the following:
• Coding should establish a clear need for skilled services under PDGM.
• Under PDGM, there will be 432 Case Mix Codes from current 153
• There will be over 43,000 ICD-10 codes that are assigned to the 12 Clinical groups
• 12 total Clinical Groups are intended to reflect the Primary Reason for Home Health Services defined by the Principal Diagnosis on the Home Health Claim.
• Claims must have a recognized primary diagnosis ICD-10 code from the APPROVED list of 43,000 codes.
• 43 of the top case mix diagnosis will have at least one comorbidity
• CMS will assign comorbidity levels based on information from the agency claim which affects reimbursement.
• 27 of the top case mix diagnosis will be found in the Neuro/Stroke or Wound Clinical Groups
• Your lower case mix scores will have no comorbidities.
• 29 low case mix scores are associated with low functional impairment based on your OASIS.
• Over 95% of top Case mixes under PDGM will rely on a medium level of impairment
• 35 case mixes are in one of the seven MMTA categories which are associated with a lower reimbursement.
• If your agency uses Abnormality of Gait or Muscle Weakness for example, it is not in the approved 43,000 codes needed to be eligible for reimbursement. Your claim will be returned.

Now why you should consider using 5 Star as your coding company:











Alice Whitehead, RN May 16, 2019
©2019 5Star Consultants, LLC

So, what will YOU do? Don’t wait too late to ensure you are prepared for the upcoming changes with PDGM. Count on a company who is already prepared and can help you survive in this new payment model.

Contact 5 Star Consultants at 866-428-4040 or www.5starconsultants.net

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MM11081 (Revised): Home Health Patient-Driven Groupings Model (PDGM) – Split Implementation

The Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles

Provider Type Affected
This MLN Matters Article is for physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for home health (HH) services provided to Medicare beneficiaries.

Provider Action Needed
CR 11081 effectuates the policies of the Patient-Driven Groupings Model (PDGM) as described in the November 2018 HH final rule. Please make sure your billing staff is aware of these changes.

Since October 2000, HH agencies (HHAs) are paid under a prospective payment system (HH PPS) for a 60-day episode of care that includes all covered HH services. The 60-day payment amount is adjusted for case-mix and area wage differences. Additionally, HH episodes of care can receive higher payments if certain therapy thresholds are met. As part of the HH PPS payment structure, HHAs receive approximately half of the expected final payment amount up front, after performing the first visit in a 60-day episode of care, with the remaining amount received at the end of the 60-day episode of care upon final claim submission.

In early February of 2018, Section 51001 of the Bipartisan Budget Act of 2018 (BBA of 2018) became law and included several requirements for HH payment reform, effective January 1, 2020. These reform measures include the elimination of the use of therapy thresholds for case-mix adjustment and a change from a 60-day unit of service to a 30- day unit of service. In the CY 2019 final HH PPS Rate Update final rule, CMS finalized an alternative case-mix method called the PDGM, which includes the payment reform requirements as set forth in the BBA of 2018 and will be implemented in CY 2020.

CR 11081 Key Points
CR 11081 effectuates the policies of the PDGM, as described in the CY 2019 HH final rule available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-and-Notices- Items/CMS-1689-FC.html and as required by Section 51001 of the BBA of 2018.
These policies include a change to the unit of payment from 60-day episodes of care to 30-day periods of care and the elimination of therapy thresholds for use in determining HH payment. The PDGM will assign 30-day periods of care into one of 432 case-mix groups based on the following variables:

yyTiming: 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;
yyAdmission Source: If the patient was referred to HH from the community or an acute or post-acute care referral source;
yyClinical Group: The primary reason the patient requires home care, represented by distinct clinical groups as determined by the principal diagnosis reported on the HH claim;
yyFunctional Impairment Level: The patient’s functional impairment level is based on OASIS items for activities of daily living; and
yyComorbidity Adjustment: If the patient has certain comorbid conditions reported on the HH claim, the 30-day period of care can receive a no, low, or high comorbidity adjustment.
In conjunction with the PDGM, this final rule implements 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.

Beginning in CY 2020, HHAs that are certified for participation in Medicare 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, would still be required to submit a “no pay” Request for Anticipated Payment (RAP) at the beginning of care to establish the HH period of care, as well as, every 30 days thereafter upon implementation of the PDGM in CY 2020.

Existing HHAs, meaning those HHAs certified for participation in Medicare prior to January 1, 2019, 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. Please note that a final claim must be submitted at the end of each 30-day period of care.

Additional Information
The official instruction, CR11081, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/ R4244CP.pdf
If you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.

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PDGM – Education is Key as you Prepare for 2020

Our first in a series of three on PDGM is basic overview of the new payment model

If you are scratching your head about the Subgroups, Clinical Groupings, Questionable Encounters, Comorbidities, etc., we will help you clear it all up!

In the November, 2018 Federal Register, CMS outlined the rationale on moving to a radically different payment approach for home health.

One of the main goals of the PDGM is to clearly account for resource use by highlighting the main reason for home health services.

    • In addition to coding guidelines, CMS also looked at clinical practice guidelines and the interventions and skilled care involved in managing the diagnosis at home.
    • CMS believes these guidelines provide valuable information for establishing a plan of care and supporting home health resource use. The Patient-Driven Groupings Model (PDGM) uses 30-day periods as a basis for payment, rather than the 60-day model. This however does NOT mean that there will be 30-day episodes for the 485 / Plan of care. A key difference is that there will no longer be Therapy Tiers for reimbursement. Instead, the Clinical Groupings will include all disciplines and along with the subgroup categories listed below, a 30-day payment will be assigned. These 30-day periods are placed into different subgroups for each of the following categories:
    • The 30-day periods are categorized into 432 case-mix groups for the purposes of adjusting payment in the PDGM.
    • However, there will be times that you will need to do a follow-up OASIS comprehensive assessment and revise the diagnoses when a patient’s status warrants it. This will then result in the billing amounts to be different for those two 30-day periods.  ​
    • Overview of the new payment model: Patient-Driven Groupings Model or PDGM
    • Reference: Federal Register/Vol. 83, No. 219/Tuesday, November 13, 2018/Rules and Regulations
    • Admission source (two subgroups): community or institutional admission source
    • Timing of the 30-day period (two subgroups): Early (first 30-day period) or Late (every concurrent payment period after the first period)
    • Functional impairment level (three subgroups): low, medium, or high based on the OASIS responses to:
      • M1800-grooming,
      • M1810-upper body dressing,
      • M1820-lower body dressing,
      • M1830-bathing,
      • M1840-toilet transferring,
      • M1850 transferring,
      • M1860 ambulation/locomotion, and
      • M1032-hospitalization risk
    • Comorbidity adjustment (three subgroups): none, low, or high based on secondary diagnosesTo make it more complex, then there are Clinical Groupings (twelve subgroups) based on the Primary diagnosis:
    • Musculoskeletal Rehabilitation
    • Neuro/Stroke Rehabilitation
    • Wounds
    • Behavioral Health Care
    • Complex Nursing Interventions
    • MMTA – Surgical Aftercare
    • MMTA – Cardiac and Circulatory
    • MMTA – Endocrine
    • MMTA – Gastrointestinal Tract and Genitourinary System
    • MMTA – Infectious Disease, Neoplasms, and Blood-Forming Diseases
    • MMTA – Respiratory
    • MMTA- Other Based on the primary diagnosis, each 30-day period will be placed into one of the 12 clinical groupings. If the primary diagnosis does not fit into one of the 12 clinical groups in the payment model, this is considered a “questionable encounter”
    • We will be delving into coding in our next in our PDGM series. Coding is extremely important in PDGM. We at 5 Star Consultants are partnering with our clients to develop strategies to implement now so they are prepared for PDGM when it goes into effect. Start now to learn all of the aspects needed to code in compliance.
    • (MMTA = Medication Management, Teaching, Assessment)

Call or Email us today to get information on how we can help you to be prepared for the biggest change in home health since PPS. To find out more about our training options, consulting and coding capabilities, contact us today at [email protected] or 866-428-4040.

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PDGM – Education is Key as you Prepare for 2020