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Summary of CMS August PDGM Call

9/5/2019 HealthWare Clinical 0 Comments

Executive Summary Horizontal Wide 1488 x 432

On August 21, 2019 CMS had a Home Health Patient Driven Groupings Model Operational Issues Call. In general, it covered much of what we already know and focused specifically on the claims submission and claims processing as a result of PDGM. It is important to note that many things stay the same under PDGM, but that there are some important changes.

Summing Up

  • Payments are calculated based on 8 OASIS items, Diagnoses, Period and Source of Admission.
  • Diagnosis codes are taken from the claim, not the OASIS.
  • Claims not OASIS are the source of payment diagnosis codes.
  • You can submit any valid HIPPS code.
  • Medicare will use data from its systems to calculate the Final HIPPS and episode payment.
  • You submit claims every 30 days.
  • You will use Occurrence code 50 to report Assessment Date.
  • You will use Occurrence codes 61 or 62 to report institutional admission sources, you must use only one, and if you use neither, the claim will be reported as a community admission source. Medicare does not use OASIS M1000 for admission source.
  • If you submit the claim with a community payment group:
  • If Medicare finds an inpatient claim with a “Through” date within 14 days of the home health “From” date they will group it into the institutional payment group.
  • If Medicare does not find an inpatient claim with a “Through” date within 14 days of the home health “From” date they will group it into the community payment group.
  • If an adjustment is made to change to an institutional payment group, it will be identified on the remittance advice.
  • If you submit a claim reflecting an institutional payment group, Medicare will not adjust to community if no inpatient claim is found after the timely filing period closes. This is because the inpatient stay may have been in a non-Medicare facility.
  • Medicare will use prior home health claim data to determine the early or late period timing.
  • If a prior claim is found within 60 days before the “From” date Medicare will group the claim as Early, otherwise, it will group it as late.
  • The transition from PPS to PDGM will treat episodes that being on or before 12/31/2019 as PPS and anything on or after 1/1/2020 as PDGM.

More Details in Case You Are Interested

You submit your OASIS very similar to how it has always been done.

One thing that is very different, the HIPPS code used when submitting the OASIS only has to be a valid HIPPS code, it does not have to be calculated using a grouper. The reason is that under PDGM you need claims data to calculate a HIPPS code. This HIPPS code will be used to calculate the split percentage payment so you really want it to be as accurate as you can get it to reflect properly in your AR, so you need to work with your software vendor to make sure you can do so.

You submit the RAP and will receive a split percentage payment.

You now provide 30 days of service and then submit a Final claim with the same HIPPS code used on the RAP, along with service line item details.

The Medicare system will combine OASIS and claim data and use their grouper to produce a HIPPS code, and that will be used for payment. This will also consider claims history and inpatient discharge information to determine period and admission source when calculating the HIPPS code.

The HIPPS code that Medicare will use in its calculation is made up of the admission source, which it will look at claims data to find previous inpatient stays, period timing, diagnoses and functional impairment level based on the values of 8 OASIS items.

  • Each 30-day period is classified into one of two admission source categories, community or institutional. This depends on what healthcare setting was utilized in the 14 days prior to home health admission.
  • The first 30-day period is classified as early. All subsequent 30-day periods in the sequence (second or later) are classified as late.
  • In addition to the primary diagnosis, PDGM includes a comorbidity adjustment based on the secondary diagnoses. You can receive no adjustment, a low adjustment or a high adjustment.
  • Low comorbidity adjustment: A secondary diagnosis is associated with higher resource use.
  • High comorbidity adjustment: Two or more secondary diagnoses are associated with higher resource use when both are reported together compared to if they were reported separately.
  • Functional impairment level is determined by 8 OASIS items, M1800, M1810, M1820, M1830, M1840, M1850, M1860 and M1033.

So, the RAP is paid based on the HIPPS code you submit on the RAP, and the Final is paid based on the HIPPS code calculated by Medicare. If your RAP was submitted with a poorly calculated HIPPS code, your final payment may vary greatly from your projected payment.


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