HH PPS v PDGM Crosswalk

HH PPS v PDGM Crosswalk-QIRT ©2019 QIRT | Floral Park, NY | Battle Creek & Troy, MI | 855.485.QIRT | QIRT.com

CURRENT HH PPS PDGM

• Early (first two 60-day episodes and greater than 60 days between)

• Late

Early (first 30-day period and greater than 60 days between) Late

Therapy Thresholds • 0 to 13 visits • 14 to 19 visits • 20+ visits

No thresholds applicable

Not applicable Institutional (14 days prior from SNF, hospital, inpatient rehabilitation

facility, inpatient psychiatric hospital, or long-term care hospital) Community

Based on annual case-mix variable table “clinical dimension” Input from:

• Coding • OASIS items • IV/infusion/parenteral/

enteral therapy • Vision • Wound • Pressure ulcers • Stasis ulcers • Surgical wounds • Shortness of breath • Bowel incontinence • Injectable drug use

30-day payment periods grouped into 1 of 12 clinical groups based on primary diagnosis (may change from initial 30-day period if change in condition):

Musculoskeletal Rehabilitation Neuro/Stroke Rehabilitation Wounds Behavioral Health Care Complex Nursing Interventions Medication Management Teaching and Assessment (MMTA) - Other Medication Management Teaching and Assessment (MMTA) – Surgical

Aftercare Medication Management Teaching and Assessment (MMTA) –

Cardiac/Circulatory Medication Management Teaching and Assessment (MMTA) -

Endocrine Medication Management Teaching and Assessment (MMTA) – GI/GU Medication Management Teaching and Assessment (MMTA) –

Infectious Disease, Neoplasms, Blood Forming Disease Medication Management Teaching and Assessment (MMTA) –

Respiratory

Classified into 1-3 functional levels based on six (6) OASIS assessment items used in the annual case mix variable table for “functional dimension”

• M1810: Ability to Dress Upper Body

• M1820: Ability to Dress Lower Body

• M1830: Bathing • M1840: Toileting Transferring • M1850: Transferring • M1860: Ambulation/

Locomotion

Classified into 1 of 3 functional levels: High Medium Low

Based on eight (8) OASIS assessment items: M1800: Grooming M1810: Ability to Dress Upper Body M1820: Ability to Dress Lower Body M1830: Bathing M1840: Toileting Transferring M1850: Transferring M1860: Ambulation/Locomotion M1033: Risk of Hospitalization

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HH PPS v PDGM Crosswalk

HH PPS v PDGM Crosswalk-QIRT ©2019 QIRT | Floral Park, NY | Battle Creek & Troy, MI | 855.485.QIRT | QIRT.com

Current HH PPS PDGM

Co-morbid diagnoses in the top 6 OASIS spots garner case-mix points if diagnosis meets conditions of case-mix status

Co-morbid adjustment given for select diagnosis in up to 25 spots on the claim. Includes none, low for a single co-morbidity meeting criteria and high for 34 select co-morbid interactions

Position 1 - Episode timing & therapy threshold

Position 2 - Clinical domain group Position 3 - Functional domain group Position 4 - Therapy utilization Position 5 - Non-routine supplies

Position 1 - Admission source & timing Position 2 - Clinical group Position 3 - Functional group Position 4 - Co-morbidity adjustment Position 5 - Unassigned

153 432

Non-routine supply add-on No non-routine supply add-on; factored into the base rate

Four or fewer visits for entire episode 432 Different LUPA thresholds ranging from 2-6 visits broken down by 30-

day periods

One RAP and one Final Claim per 60-day episode

One RAP and one Final Claim for each 30-day payment period. Agencies started after 1/1/19, must submit a no-pay RAP and final claim

Applied to all rural areas uniformly

Varying add-on amounts depending on the rural country classification classified as such:

High Utilization (high Medicare episode areas) Low Population (population density of 6 individuals or fewer per

square mile of land area. All other

Certifying physician as part of recertification statement, must provide an estimate of how much longer skilled services are required

As of 1/1/19, physician does not need to provide estimate of how much longer skilled services are required.

None reimbursable Costs are an allowable administrative cost if it is used by the home health agency to augment the care planning process. It will not be reimbursed as a substitute for an in-person home visit.

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WHAT STAYS THE SAME Plan of Care is every 60 days | Partial Episode Payments; same methodology OASIS is completed every 60 days | Outliers; same methodology Budget neutral except for behavioral adjustment

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