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5/10/19
QIRT ©2019 1
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Y O U R P A R T N E R O N T H E J O U R N E Y T O Q U A L I T Y
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Sherri Parson RN HCS-D HCS-O HCS-H COS-C BCHH-C
• Over 25 yrs health care experience including inpatient hospital settings as a direct care provider for Medical Surgical, ICU, and Interventional Radiology before transitioning to home health.
• Over 14 years of home care experience as direct care provider, QA, coding and OASIS reviewer, therapy manager, staff education and development expert
• Providing high-level clinical education at QIRT since 2012
• Certified as Home Care Clinical Specialist –Diagnosis, OASIS and Hospice (HCS-D, HCS-O, HCS-H) . Board Certified Home Health Coding (BCHH-C) and OASIS Specialist-Clinical (COS-C)
VP of Education and Control Standards QUALITY IN REAL TIME (QIRT)
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PDGM JEOPARDY
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PRACTICE:
What is July 4th?
uAnswer: A national holiday celebrating the anniversary of the adoption of the Declaration of Independence in 1776.
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Jeopardy
$100
OASISin the Mix
It’s Questionable
PrimaryFocus
It All Adds UpHit Me in thePocketbook
$200
$300
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Final Jeopardy
OASIS in the Mix- $100
What non-ADL M item(s) has been added to the PDGM functional calculations?
uAnswer: M1033 Risk of Hospitalization
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M1033 Risk for Hospitalization had been added to the calculation of the OASIS functional level.
This item will use clinician judgement to answer the characteristics that may indicate the patient is at risk for hospitalization. Does not include #8, 9, or 10.
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OASIS in the Mix - $200
What are all the possible functional levels in PDGM?
uAnswer: High, medium, and low functional impairment levels.
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PDGM OASIS Items
uUsing the answers from the eight M questions included in the PDGM, the patient will be classified as:
Low Functional Impairment Level
Medium Functional Impairment Level
. High Functional Impairment Level
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OASIS Functional Points in PDGMOASIS Item OASIS Answer Response Category Points
M18000 or 1
2 or 3
-
1
0
4
M18100 or 1
2 or 3
-
1
0
6
M18200 or 1
23
-
12
0
511
M1830
0 or 1
23 or 45 or 6
-
123
0
31321
M18400 or 1
2, 3, or 4
-
1
0
4
M18500
12, 3, 4, or 5
-
12
0
48
M1860
0 or 1
234, 5, or 6
-
123
0
101224
M10334 items or more checked,
excluding #8, 9, 10 - 11
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PDGM Functional Thresholds
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OASIS in the Mix - $300
What are the OASIS items used in the calculation of functional level in PDGM?
Answer: M1800 Grooming, M1033 Risk of hospitalization, M1810 Upper body dressing, M1820 Lower body dressing, M1830 Bathing, M1840 Toilet transfer, M1850 Transferring, and M1860 Ambulation.
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PDGM OASIS Functional Items
13
PDG
M O
ASI
S Fu
nctio
nal I
tem
s
M1800 Grooming
M1810 Current Ability to Dress Upper Body
M1820 Current Ability to Dress Lower Body
M1830 Bathing
M1840 Toilet Transferring
M1850 Transferring
M1860 Ambulation
M1033 Risk of Hospitalization
New with PDGM
Current Items
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OASIS in the Mix- $400
What OASIS items were initially considered for inclusion in PDGM functional calculations but left off?
Answer: Cognition, pain, and respiratory OASIS items.
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Excluded OASIS Items
uCognitive items were looked at closely for inclusion, however research data indicated that these items demonstrated a decrease in resource use and therefore were not included.
uOther OASIS items considered but left out of model:
u M1220 and M1230*
u M1242
u M1400
u Ulcer and wound items
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OASIS in the Mix - $500
The most frequent OASIS response in the OASIS (2017 data)?
Answer: M1810 response 2 and 3 (response category 1).
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OASIS Functional Points in PDGM and Response Percentages
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It’s “Questionable” - $100
What is a Questionable, RTP (return to provider), or non-valid diagnosis?
Answer: Any diagnosis used in M1021 that is not approved by CMS for use as a primary diagnosis for home care.
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Sample of CMS ICD-10 Grouper ListYou can find the Diagnosis Grouper List at:
u https://www.cms.gov/center/provider-type/home-health-agency-hha-center.html
A15.6 Tuberculous pleurisy MMTA_INFECT A15-A19 TuberculosisA15.7 Primary respiratory tuberculosis MMTA_INFECT A15-A19 TuberculosisA15.8 Other respiratory tuberculosis MMTA_INFECT A15-A19 TuberculosisA15.9 Respiratory tuberculosis unspecified MMTA_INFECT A15-A19 TuberculosisA17.0 Tuberculous meningitis NEURO_REHAB A15-A19 TuberculosisA17.1 Meningeal tuberculoma NEURO_REHAB A15-A19 TuberculosisA17.81 Tuberculoma of brain and spinal cord NEURO_REHAB A15-A19 TuberculosisA17.82 Tuberculous meningoencephalitis NEURO_REHAB A15-A19 TuberculosisA17.83 Tuberculous neuritis NEURO_REHAB A15-A19 TuberculosisA17.89 Other tuberculosis of nervous system NEURO_REHAB A15-A19 TuberculosisA17.9 Tuberculosis of nervous system, unspecified NEURO_REHAB A15-A19 TuberculosisA18.01 Tuberculosis of spine MS_REHAB A15-A19 TuberculosisA18.02 Tuberculous arthritis of other joints MS_REHAB A15-A19 TuberculosisA18.03 Tuberculosis of other bones MS_REHAB A15-A19 TuberculosisA18.09 Other musculoskeletal tuberculosis MS_REHAB A15-A19 TuberculosisA18.11 Tuberculosis of kidney and ureter MMTA_INFECT A15-A19 TuberculosisA18.12 Tuberculosis of bladder MMTA_INFECT A15-A19 TuberculosisA18.13 Tuberculosis of other urinary organs MMTA_INFECT A15-A19 Tuberculosis
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It’s “Questionable” - $200
What codes represent the largest group of questionable/non-valid/RTP diagnosis in PDGM?
Answer: Chapter 18 of the coding manual and symptom codes.
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Remember Coding Guidance:
4. Signs and symptoms Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many, but not all, codes for symptoms. See Section I.B.18 Use of Signs/Symptom/Unspecified Codes
5. Conditions that are an integral part of a disease process Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
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It’s “Questionable” - $300
Which vague symptom code is used most frequently as a primary diagnosis in home care?
Answer: M62.81 Muscle weakness
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CoPs and M62.81
u409.44(c)(1)(a) of the CoPs state “the patient’s clinical record must include documentation describing how the course of therapy treatment for a patient’s illness or injury is in accordance with acceptable professional standards of clinical practice.”
u If there is not an identified cause of muscle weakness then it would be questionable whether the course of therapy treatment would be in accordance with professional standards.
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Muscle Weakness M62.81
uThe HH PPS Final Rule of 2008: Muscle weakness was also identified as a nonspecific condition that represents general symptomatic complaints in the elderly population.
uIt was further stated that inclusion of such codes into case mix status “would threaten to move the case mix model away from a foundation of reliable and meaningful diagnosis codes that are appropriate for home care”.
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ICD 10 CODE DESCRIPTIONRANK FREQUENCY
M62.81 Muscle weakness (generalized) 3R26.89 Other abnormalities of gait and mobility 24M54.5 Low back pain 33R26.81 Unsteadiness on feet 37R53.1 Weakness 38R26.9 Unspecified abnormalities of gait and mobility 42R29.6 Repeated falls 43R26.2 Difficulty in walking, not elsewhere classified 51M19.90 Unspecified osteoarthritis, unspecified site 57Z48.89 Encounter for other specified surgical aftercare 61M06.9 Rheumatoid arthritis, unspecified 71Z51.89 Encounter for other specified aftercare 76R33.9 Retention of urine, unspecified 82R55 Syncope and collapse 92C34.90 Malignant neoplasm of unsp part of unsp bronchus or lung 93M19.91 Primary osteoarthritis, unspecified site 96Z91.81 History of falling 100R13.10 Dysphagia, unspecified 101M25.561 Pain in right knee 102R42 Dizziness and giddiness 108M54.9 Dorsalgia, unspecified 111M25.551 Pain in right hip 117
Top 20 Non-valid Primary Codes in PDGM (2017 data)
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It’s “Questionable” - $400
What cannot be missing from a valid primary wound diagnosis in PDGM?
Answer: Wounds with unspecified severity are sometimes okay, but unspecified laterality is never okay.
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Example of “valid” primary wound codes with some unspecificity.
L97.429 Non-prs chronic ulcer of left heel and midfoot w unsp severt WOUND
L97.511 Non-prs chronic ulcer oth prt r foot limited to brkdwn skin WOUND
L97.512 Non-prs chronic ulcer oth prt right foot w fat layer exposed WOUND
L97.513 Non-prs chronic ulcer oth prt right foot w necros muscle WOUND
L97.514 Non-prs chronic ulcer oth prt right foot w necrosis of bone WOUND
L97.515Non-pressure chronic ulcer of other part of right foot with muscle involvement without evidence of necrosis WOUND
L97.516Non-pressure chronic ulcer of other part of right foot with bone involvement without evidence of necrosis WOUND
L97.518Non-pressure chronic ulcer of other part of right foot with other specified severity WOUND
L97.519 Non-prs chronic ulcer oth prt right foot w unsp severity WOUND
L97.521 Non-prs chronic ulcer oth prt l foot limited to brkdwn skin WOUND
L97.522 Non-prs chronic ulcer oth prt left foot w fat layer exposed WOUND
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Wound Coding
uIt is not uncommon to be unable to determine the severity of a wound or ulceration.
uHowever, if the HHA has this wound as their focus of care (primary diagnosis) then they should know where the wound they are treating is located.
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It’s “Questionable” - $500
How do you capture the correct clinical grouping for the second 30 days if the clinical grouping changes from the first 30 days?
Answer: The “Other Follow-up OASIS” should be completed during an episode to help capture this if there has been a significant change in condition.
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Updating the Assessment
uCoP 484.55(d)(1)(ii) states HHA are required to update the comprehensive assessment.
uCoP 484.18(b) every 60 days (or more frequently) the total plan of care is reviewed by the attending physician and HHA personnel as often as the patient’s condition requires, or when there is a beneficiary elected transfer, or a significant change in condition resulting in a change in the case-mix assignment, or discharge and return to the same
HHA during the 60-day episode.
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A follow-up assessment would be submitted before the start of the second 30-day period to reflect a major change in condition and then the second 30-day claim would be grouped in appropriate case mix group.
This is different than the current payment model where a case mix group does not change in the middle of a 60-day episode. However, similar to the current system the case mix group cannot be adjusted within the 30-day period.
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Primary Focus - $100
What is a clinical grouping in PDGM?
Answer: Determined by the principle diagnosis on the claim, this captures most of the common types of care provided.
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Clinical Groups
According to the final rule, this is a way to capture the common types of care provided and more accurately align payments with the costs of providing care or in other words: resource use.
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Primary Focus - $200
Why were the clinical subgroups of MMTA created?
Answer: Created to help further distinguish this clinical grouping and the differences in care to allow for greater transparency in resource use, not because of any increase in resource utilization currently.
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The 7 MMTA Subgroups:MMTA –Surgical Aftercare
MMTA – Cardiac/Circulatory
MMTA – Endocrine
MMTA – GI/GU
MMTA – Infectious Disease/Neoplasms/Blood-forming Diseases
MMTA –Respiratory
MMTA – Other
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MMTA
Addition of the 7 MMTA groups now creates 432 case-mix weight for the model.
The thought is: by creating these discrete subgroups within MMTA, over time there may be more variation between resources.
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Primary Focus - $300
Why should the primary diagnosis be a specific diagnosis?
Answer: They do not support individualized plans of care.
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CoP 484.60
• The plan of care must specify the services necessary to meet patient-specific needs as identified in the comprehensive assessment.
• This includes identification of the anticipated measurable outcomes as a result of implementing and coordinating a plan of care.
• Using signs and symptoms as a principle diagnosis would make it difficult to meet the requirements of the an individualized plan of care.
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Plan of Care
• Interventions and treatment aimed at mitigating signs and symptoms of the condition may vary depending on the cause.
• For example: R26.89 “other abnormalities of gait and mobility” would require the clinician to know what is precipitating the abnormality. A plan of care for gait issues related to a neurological diagnosis is different than a gait abnormality related to an injury.
• “By the time a patient is referred to home health and meets the qualifications of eligibility, we would expect that a more definitive code exists to substantiate the need for services.”
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Primary Focus - $400
What criteria did CMS use to select the diagnoses allowable as primary in PDGM?
Answer: Ø Resources use in home health
Ø Main reason for home health
Ø Need for home health
Ø Coding conventionsØ Clinical practice guidelines
Ø Skilled care involved in managing diagnoses at home
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“Valid” Primary Diagnoses
uSelection of the ICD-10 codes allowable as primary were agreed upon by many factors.
uFirst, that it clearly accounted for resource uses and the driving force of the home health episode.
uSupports need…for example: dental codes do not
uRelevancy…for example: if there is a death outcome, such as brain death, this would not be relevant for home health
uCoding guidelines and sequencinguClinical practice guidelines and interventions uSkilled care involved in managing specific diagnoses at
homeuFor example: a simple infection may not necessitate
wound care.
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Primary Focus - $500
How often will the ICD 10 CM codes related to PDGM be updated?
Answer: Annually, the ICD-10-CM coding set will have 2 grouper releases: one in October and one in January.
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• The final rule cited examples of code updates related to the grouper updates.
• Addition of the following codes after comments:• Exact type of fracture (site should be identified)• I13.2 unlikely patient is covered under ESRD benefit for
hypertension• Z46.6 Encounter for fitting and adjustment of urinary
device now grouped under Complex Nursing clinical group
• A41.9 Sepsis approved since the underlying code for the systemic infection should be listed first
• https://www.cms.gov/center/provider-type/home-health-agency-hha-center.html
PDGM Regrouping of Codes
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It All Adds Up - $100
How many case-mix groups are found in PDGM?
Answer: There are 432 of these is PDGM
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HHRGs in PDGM
Admission Status and Episode Timing (4)
Clinical Groupings (from Primary Diagnosis on claim) (12)
Functional Level (from OASIS items) (3)
Comorbid Adjustment (from secondary diagnosis on claim) (3)
4 X 12 X 3 X 3 = 432
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It All Adds Up - $200
What affect does episode timing have on the case-mix index?
Answer: CMI will be lower with Late episode timing vs. Early episode timing.
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Two 30-Day Payment Episodes
OASIS
60-Day Episode of Care
30-Day Payment Period
30-Day Payment Period
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Episode Timing
Early = First 30-day episode or if there is greater than 60 days between episodes
Late = Anything not in the first 30-day episode
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Comparison of case mix weights of Early and Late episodes
PDGM Episode Timing
Admission Source/Timing
Clinical Group/Functional Group
Comorbid Adjustment
HIPPS CMI
Institutional -Late Wound - Low No 4CA11 1.2627
Institutional-Late Wound - Low Low 4CA21 1.3223
Institutional-Late Wound - Low High 4CA31 1.4474
Institutional -Late Wound - High No 4CC11 1.5347
Institutional -Late Wound - High Low 4CC21 1.5944
Institutional -Late Wound - High High 4CC31 1.7194
Admission Source/Timing
Clinical Group/Functional Group
Comorbid Adjustment
HIPPS CMI
Institutional/Early Wound - Low No 2CA11 1.4019
Institutional/Early Wound - Low Low 2CA21 1.4615
Institutional/Early Wound -Medium High 2CB31 1.7391
Institutional/Early Wound - High No 2CC11 1.6739
Institutional/Early Wound - High Low 2CC21 1.7335
Institutional /Early Wound - High High 2CC31 1.8586
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It All Adds Up- $300
How many high and low comorbidity adjustments are there in PDGM?
Answer: 13 Comorbid Subgroups and 34 comorbidity subgroup interactions
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Comorbidity Subgroup
Description
Cerebral 4 Includes sequelae of cerebral vascular diseases
Circulatory 10 Includes varicose veins with ulceration
Circulatory 9* Includes acute and chronic embolism and thrombosis
Heart 10 Includes cardia dysrhythmias
Heart 11 Includes heart failure
Neoplasms 1* Includes oral cancers
Neuro 10 Includes peripheral polyneuropathies
Neuro 11* Includes diabetic retinopathy and other blindness
Neuro 5 Includes Parkinson’s disease
Neuro 7 Includes hemiplegia, paraplegia, and quadriplegia
Skin 1 Includes cutaneous abscess, cellulitis, lymphangitis
Skin 3 Includes diseases of arteries, arterioles, and capillaries with ulceration and non pressure, chronic ulcers
Skin 4 Includes stages 2 through 4 and unstageable ulcers
Low Comorbidity Adjustment
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High Comorbidity Interaction Adjustment# Group Includes Group Includes
1 Behavioral 2 Depression and Bipolar Skin 3 Vessel ulceration/non-pressure
2 Cerebral 4 Cerebral Vascular Disease Circulatory 4 Hypertensive CKD
3 Cerebral 4 Cerebral Vascular Disease Heart 10 Cardiac dysrhythmias
4 Cerebral 4 Cerebral Vascular Disease Heart 11 Heart Failure
5 Cerebral 4 Cerebral Vascular Disease Neuro 10 Peripheral/polyneuropathy
6 Circulatory 10 Varicose vein ulceration Endocrine 3 Diabetes with Complications
7 Circulatory 10 Varicose vein ulceration Heart 11 Heart Failure
8 Circulatory 4 Hypertensive CKD Skin 1 Abscess, cellulitis, lymphangitis
9 Circulatory 4 Hypertensive CKD Skin 3 Vessel ulceration/non-pressure
10 Circulatory 4 Hypertensive CKD Skin 4 Pressure stage 2-4, unstag.
11 Circulatory 7 Atherosclerosis Skin 3 Vessel ulceration/non-pressure
12 Endocrine 3 Diabetes with Complications Neuro 5 Parkinson’s
13 Endocrine 3 Diabetes with Complications Neuro 7 Hemi/para/quadriplegia
14 Endocrine 3 Diabetes with Complications Skin 3 Vessel ulceration/non-pressure
15 Endocrine 3 Diabetes with Complications Skin 4 Pressure stage 2-4, unstag.
16 Heart 10 Cardiac dysrhythmias Skin 4 Pressure stage 2-4, unstag.
17 Heart 11 Heart failure Neuro 10 Peripheral/polyneuropathy
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High Comorbidity Interaction Adjustment# Group Includes Group Includes
18 Heart 11 Heart Failure Neuro 5 Parkinson’s
19 Heart 11 Heart Failure Skin 3 Vessel ulceration/non-pressure
20 Heart 11 Heart Failure Skin 4 Pressure stage 2-4, unstag.
21 Heart 12 Other heart diseases Skin 3 Vessel ulceration/non-pressure
22 Heart 12 Other heart diseases Skin 4 Pressure stage 2-4, unstag.
23 Neuro 10 Peripheral/polyneuropathy Neuro 5 Parkinson’s
24 Neuro 3 Dementias Skin 3 Vessel ulceration/non-pressure
25 Neuro 3 Dementias Skin 4 Pressure stage 2-4, unstag.
26 Neuro 5 Parkinson’s Renal 3 Nephrogenic Diabetes Ins
27 Neuro 7 Hemi/para/quadriplegia Renal 3 Nephrogenic Diabetes Ins
28 Renal 1 CKD ESRD Skin 3 Vessel ulceration/non-pressure
29 Renal 1 CKD ESRD Skin 4 Pressure stage 2-4, unstag.
30 Renal 3 Nephrogenic Diabetes Ins. Skin 4 Pressure stage 2-4, unstag.
31 Resp 5 COPD asthma Skin 3 Vessel ulceration/non-pressure
32 Resp 5 COPD asthma Skin 4 Pressure stage 2-4, unstag.
33 Skin 1 Abscess, cellulitis, lymphangitis Skin 3 Vessel ulceration/non-pressure
34 Skin 3 Vessel ulceration/non-pressure Skin 4 Pressure stage 2-4, unstag.
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It All Adds Up - $400
What is behavioral adjustment?
Answer: CMS believes agencies will quickly adjust to coding changes to maximize their reimbursement.
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Budget Neutral
uThe BBA congressionally mandated PDGM to be budget neutral or rather it would not result in an overall reduction in Medicare reimbursements for the home health industry.
uHowever, CMS has made certain assumptions about how HHA will respond to the new payment model.
uBased on these assumptions, they have lowered the 30-day payment amount needed to be neutral down, calling it a “behavioral adjustment”.
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30-Day Payment Amount
uBudget neutrality suggested $1864
uCMS institutes a 6.24% lower payment amount, as a “behavioral adjustment” and has set the 30-day payment amount at $1754
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It All Adds Up - $500
How will split-percentage payment (RAP) be handled in PDGM?
Answer: Agencies existing prior to January 1, 2019 will receive 60/40 for first 30-day period and 50/50 for all subsequent 30 day periods.
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RAP Payments
uRap payments can result in vulnerabilities.
uFraudulent agencies submit a RAP but never a final bill.
u In the PDGM proposed rule, CMS detailed specific instances of severe abuse.
uOne agency in Michigan submitted a total of over 50 million in RAP payments and received over 37 million in RAP payments but never submitted a claim over 10 months. When CMS went out to the home health agency address, it was vacant.
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RAP Payments
uAs a result of millions in fraudulent RAPs, newly-enrolled home health agencies, on or after January 1, 2019 will need to submit a “no pay” RAP.
uThe thought is: eventually the RAP payments for all agencies will phase out.
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Hit Me in the Pocketbook! - $100
What is a the frequency of LUPA or Low Utilization Payment Adjustment in HH PPS?
Answer: 8% of all episodes in the current HH PPS model represents this alternate reimbursement.
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LUPAs
uCurrently 8% of episodes fall under the special low utilization payment adjustment (LUPA).
uIn HH PPS, a low utilization payment is calculated when an episode is fewer than 5 visits
uLUPA adjustment will continue in PDGM but the threshold needed to be recalculated due to the shorter 30-day payment period.
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Hit Me in the Pocketbook!- $200
How is the LUPA calculation in PDGM?
Answer: The 10th percentile value of each visit of each clinical grouping or 2 visits, whichever is higher.
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LUPA Methodology
uBy calculating the low utilization adjustment by clinical groups, CMS felt this method of calculation would accomplish a few things:
1) Better reflect the patient’s clinical characteristics
2) Lowers the ability to “game” the system
3) Current method would have resulted in more LUPAs due to 30 day payment episode
4) Puts minimal burden on agencies since episodes billed the same as any other claim
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TABLE 32 - LUPA Thresholds for PDGM
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Hit Me In The Pocketbook! - $300
What is the projected amount of LUPA episodes in PDGM?.
Answer: 7.1% of all episodes across all clinical groups are projected to fall in this reduced home health alternate payment.
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LUPAs in PDGM
uThe 10th percentile of each clinical group was decided upon based on the fact that this obtained the 7.1% amount of LUPAs the closest to the current 8% level of LUPAs in the HHPPS payment model.
uWill be re-evaluated each year based on most current data available
uCY2020 will be updated using the HH PPS CY2018 home health data
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Hit Me in the Pocketbook! - $400
What is the clinical grouping requiring the highest number of visits for a LUPA?
Answer: 6 visits with Musculoskeletal Rehab medium/high and early/institutional
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MS Rehab
uRequires the highest utilization to avoid LUPA status
uBy nature, MS rehab represents what CMS considers to be primarily a therapy episode. Therapy episodes often represent the highest utilization of resources.
uThere is no difference in the LUPA threshold related to the presence of comorbid diagnoses solely based on the primary diagnosis.
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Hit me in the pocketbook - $500
How is NRS calculated for LUPAs?
Answer: Included in the clinical group per visit based on recaliberated data for supply utilization when thresholds fall below 10th percentile.
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NRS and LUPA’s
uConcerns raised during comment period that NRS would not be sufficiently covered. These costs seem to be related to functional levels and patient needs.
uCMS answered that this methodology of including NRS with the per visit adjustment with LUPAs has been rebased and is the highest it can be by law.
uCMS points out that though some LUPA thresholds are affected by the functional scores, that OASIS data is looked at a whole and it is important that agencies have the OASIS accurately reflect the services provided.
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Final Jeopardy
What is the highest and lowest paying clinical groupings?
Answer: Behavioral Health clinical grouping late/ community, low functional impairment level is the lowest CMI and Wound clinical grouping early/institutional, high functional impairment level has the highest CMI.
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Case Mix IndexLowest Behavioral to Highest Wound
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Behavioral Clinical GroupingLate/CommunityLow Functional impairmentNo co-morbid adjustment$1754 x 0.5015 = $879.31
Low Payment Comparison
Wound Clinical GroupingEarly InstitutionalHigh Functional ImpairmentHigh Co-morbid Adjustment$1754 X 1.8586 = $3259. 98
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QUICK REVIEW
OASISin the Mix
• 3 functional impairment levels: Low, Medium, High• Calculated from M1800, M1810, M1820, M1830, M1840,
M1850, M1860, M1033.• Other items considered in for functional impairment but
left off model: pain, cognition, breathing, and wounds.• Responses for M items are divided into response
categories, points awarded to categories• Point totals then correspond to clinical grouping
©2019
QUICK REVIEW
It’s Questionable
• What’s meant by questionable, RTP, or non-valid primary code
• How to find out if diagnosis is an acceptable primary in PDGM
• Significance of specific codes and trouble with symptom codes
• Top 20 questionable diagnoses• Renewed importance of the follow-up assessment
What we have covered:
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QUICK REVIEWPrimaryFocus
• Definition of primary diagnosis and added importance in PDGM
• MMTA subgroups and anticipated importance of division
• Why and how primary diagnosis support POC and symptoms don’t
• Criteria CMS used to develop list of acceptable PDGM primary diagnoses
• How and when the ICD-10-CM grouper will be updated
What we have covered:
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QUICK REVIEW
It All Adds Up
• What goes into the 432 case-mix clinical groupings• How the 60-day OASIS episode breaks down into
two 30-day payment periods• Episode timing and the negative effect late timing
has on case mix• Comorbidities that generate low adjustment• Comorbidities that interact for high adjustment• Behavioral adjustment and budget neutrality• Split payments and RAP payments
What we have covered:
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QUICK REVIEW
• Low Utilization Payment Adjustment and percentage predicted occurrence in PDGM
• Methodology for calculating LUPAs in PDGM• How frequently this will be updated• The clinical groupings with the highest LUPA
thresholds• How NRS are calculated with LUPAs
Hit Me In ThePocketbook
What we have covered:
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References:
u Medicare Learning Network: Overview of the Patient-Driven Groupings Model (PDGM) February 12, 2019, file:///C:/Users/pamel/Documents/PDGM/CMS%20Presentation_2019-02-12-PDGM.pdf
u Medicare Home Health Prospective Payment System: Case-Mix Methodology Refinements, Overview of the Home health Groupings Model, https://downloads.cms.gov/files/hhgm%20technical%20report%20120516%20sxf.pdf
u Centers for Medicare & Medicaid Services Patient-Driven Groupings Model: Overview of the Patient-Driven Groupings Model, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/Overview-of-the-Patient-Driven-Groupings-Model.pdf
u Federal Register/Vol. 83, No. 219/Tuesday, November 13, 2018/Rules and Regulations,
(CMS-1689-FC), https://www.govinfo.gov/content/pkg/FR-2018-11-13/pdf/2018-24145.pdf
u www.CMS.gov, Home Health Agency (HHA) Center: PDGM Grouper Tool CY 2019 (Updated 11/06/2018), and CY 2019 Case-Mix Adjustment Variables and Scores (Table 3).
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