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4/1/2019
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Shifting Gears: Preparing for PDGM
Jennifer Collins BSN, RN, HCS-D, COS-C
Disclaimer
• This material is designed and provided to communicate information about the 2019 Final Rule application, compliance, ethics and accuracy in an educational format and manner.
• The author is not providing or offering legal advice, but rather practical and useful information to achieve compliant results in the area of case mix methodology, compliance, clinical documentation, quality, and coding.
• Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful.
Objectives
• Define the structure of PDGM • Review the behavioral assumptions used in calculating 30 day
budget neutral payments• Awareness of comprehensive assessment components and
their impact on PDGM• Learn actions steps and timeline in preparation for PDGM
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CY 2020 CASE-MIX ADJUSTMENT METHODOLOGY REFINEMENTS
Review: 2019 Final Rule
2019 HH PPS: Final Rule
• Summarizes the case-mix methodology refinements for home health services beginning on or after January 1, 2020
– Includes the elimination of therapy thresholds for payments and
– A change in the unit of payment from a 60-day episode to a 30-day period
– Relies clinical characteristics and other patient information to place patients into clinically meaningful payment categories
– Estimated costs of care using information from the Medicare Cost Report: Cost-Per-Minute plus Non-Routine Supplies (CPM+NRS)
Bipartisan Budget Act of 2018
• Section 51001(a)(1)(B)– Requires 30 day episodes of care as units of payment
• Section 51001(a)(3)(B)– Eliminates the use of the number of therapy visits provided to
determine payment
• Effective January 1, 2020
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CPM + NRS
• Cost-per-Minute plus Non-Routine Supplies (CPM+NRS) approach to estimating resource use– Information from HHA Medicare cost reports
• Total cost of each of the 6 HH disciplines for each HHA• Number of visits by each of the 6 HH disciplines for each HHA• Calculate discipline-specific cost per visit values
CPM + NRS
• CPM+NRS– Information from HH claims data
• Average number of minutes of care provided by each discipline across all episodes for each HHA
• Average number of visits provided by each discipline across all episodes for each HHA
• Calculate a ratio of average visits to average minutes of care by discipline
• Calculate cost per minute (multiply cost per minute by ratio of average visits to average minutes)
• Obtain 30-day period costs (multiply costs per minute by total number of visits of care provided by during a 30 day period by discipline, then sum the costs across the disciplines for each period)
CPM + NRS
• CPM+NRS– From Cost Reports: Determine NRS cost-to-charge ratio for each HHA– From Claims Data: Obtain NRS charges for each period– NRS Costs for each period: Multiply charges from HH Claims Data by
cost-to-charge ration from the cost reports
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Patient-Driven Groupings Model: PDGM
30-day Periods placed into subgroups of each of the following:• Timing of the 30-day Period: Early or Late• Admission Source: Community or Institutional• Clinical Groupings: 6 Groups with 7 MMTA subgroups based on
primary diagnosis• Functional Impairment Level: Low, Medium, or High• Comorbidity Adjustment: None, Low or High based on
secondary diagnoses
PDGM: Change from 60 to 30-Day Unit of Payment
• Considerations:– Billing versus Certification
• Two 30-day units of payment inside one 60 day certification– Administrative Burden with extra billing cycles– Administrative Burden with obtaining physician signatures
• Final claim submission requires a completed OASIS assessment, signed certification, orders and plan of care (same as current)
– Clarification of implementation date of January 1, 2020– ROC / Diagnosis changes and updates
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PDGM: Assumptions about Behavior Change
• Section 1895(b)(3)(A)(iv):– Budget neutral calculations of estimated aggregate expenditures– “make assumptions about, and take into account behavior changes
that could occur as a result of the implementation of the 30-day unit of payment and case-mix adjustment factors in CY 2020.• Clinical Group Coding• Comorbidity Coding• LUPA Threshold• Estimated 6.42% decrease in payment
PDGM: Timing
• Early: The first 30-day period
• Late: All subsequent 30-day periods in the sequence (second or later)
• A sequence of 30-day periods continues until there is a gap of at least 60 days between the end of one 30-day period and the start of the next
• Claims-Based
PDGM: Admission Source
• Admission Source Categories determined by the healthcare setting utilized in the 14 days prior to home health admission:– Institutional includes beneficiaries with inpatient stays at:
• Acute-Care Hospitals**• Inpatient Rehab Facilities• Long Term Care Hospitals• Inpatient Psychiatric Facilities• Skilled Nursing Facilities
– Community
**Patients that had an acute care hospital stay during a previous 30-day period of care and within 14 days prior to the subsequent, contiguous 30-day period of care and for which the patient was not discharged from home health and readmitted – also included in institutional category
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PDGM: Admission Source and Timing
*CMS developed automated claims processing procedures with the goal of reducing the amount of administrative burden associated with the admission source category of PDGM
PDGM: Admission Source
• Considerations:– Hospice, ED visits, ASC, Observation stays– Preventative and Maintenance Therapy– Institutional claims issues, timely filing, etc.– Use of occurrence codes – Post-Payment Medical Review
PDGM: Clinical Grouping
Represent the primary reason for home health care
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PDGM: Clinical Grouping
• Considerations:– Unspecified Codes– R-Codes (Signs and Symptoms)– M62.81, “Muscle weakness, generalized”– S and T Codes– Combination Codes– Signification Change in Condition with diagnosis change
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PDGM: Functional Impairment Levels
• Considerations– Maintenance Therapy– Cognitive Status– Pain and Dyspnea– Patient-centered care vs payment-driven care
• Low Comorbidity Adjustment: One reported secondary diagnosis in one of the home-health specific individual comorbidity subgroups (listed in Table 30)
• High Comorbidity Adjustment: Two or more reported secondary diagnoses in one or more of the comorbidity subgroup interactions (listed in Table 31)
• No Comorbidity Adjustment: No secondary diagnoses exist or none meet the criteria
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PDGM: Comorbidity Adjustment
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PDGM: Comorbidity Adjustment
• Considerations:– Payment adjustments are the result of actual resource utilization as
reported on home health claim analysis – Behavioral Health Care– Example: Pressure ulcer development after CVA
PDGM: LUPA Threshold
• Vary depending on the PDGM payment group • Set at the 10th percentile value of visits or 2 visits, whichever is higher
• Considerations:– CY 2017 utilization data analysis:
• 60-day episodes under HHPPS = approximately 8%• 30-day periods under PDGM = approximately 7%
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PDGM: Adjustments
• LUPA Add-On: No change except applied to 30 day periods of care under PDGM
• Partial Episode Payments: Retain current PEP policy and apply such policy to 30-day periods of care under PDGM
• High-Cost Outliers: Maintain the current methodology for payment of high-cost outliers upon implementation of PDGM with payment calculations based upon 30-day periods of care
DISCUSSIONPrepare: CY 2020 PDGM Implementation
PDGM: Preparation
• Intake / Referral Processes Refinement:– Impacts Episode Timing, Admission Source, Clinical Grouping and
Comorbidity– Documents containing patient past medical history (i.e.: Diagnoses)
• Consider Community Referrals– Checklists and Scripting
• Ease for referral source• Troubleshooting needed documentation
– Coordination with Sales and Marketing Team
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PDGM: Preparation
• OASIS Accuracy– Staff Education– Collaboration– Observation vs interview– Consider impact of all time points:
• SOC/RC• ROC/SCIC• Transfer with/without DC• Discharge
PDGM: Preparation
• Coding– Questionable Episodes– Behavior Adjustment for Coding– Claims versus OASIS
• Primary Diagnosis and up to 24 Secondary Diagnoses– Changes mid-episode (ROC, SCIC)– Must continue to follow coding guidelines– Require physician documentation
PDGM: Preparation
• Back Office:– Evaluate and Refine Processes:
• Days to RAP• Days to Final Claim• Order Entry, approval, delivery to physician• Consider mid-episode variations:
–ROC assessments and orders–SCIC
– Occurrence Codes (need further clarification)
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PDGM: Preparation
• Care Coordination– OASIS Collaboration (Functional and M1033)– Diagnosis selection– Maintain high quality, outcome focused care– Therapy and Aide for consistent reinforcement of patient safety with
transfers, bathing, etc.– Enhance patient engagement– Goal driven care– LUPA awareness and prevention
PDGM: Preparation
• Utilization Management:– Appropriate, cost effective skill utilization to meet patient need– Patient Specific– Review:
• Number of visits per discipline per episode• Costs per episode• Length of stay• LUPA management
Resources:
Medicare and Medicaid Programs; CY 2019 Home Health Prospective Payment System Rate Update and CY 2020 Case-Mix Adjustment Methodology Refinements; Home Health Value Based Purchasing Model; Home Health Quality Reporting Requirements; Home Infusion Therapy Requirements; and Training Requirements for Surveyors of National Accrediting Organizations
https://www.govinfo.gov/content/pkg/FR-2018-11-13/pdf/2018-24145.pdf
