New Medicare Home Health Care Payment Grouper — Are You Ready?

November 25th, 2019 - Wyn Staheli, Director of Research
Categories:   Home Health|Hospice  

Home Health’s biggest change in two decades begins January 1, 2020 when CMS will begin using a new Patient-Driven Groupings Model (PDGM) for home health payments. This new system has several key factors:

  • Diagnosis drivenThe payment rate factors in the patient’s primary and secondary diagnoses. More complex conditions will have a higher payment rate.  
    • Primary diagnosisThis describes the primary reason the patient is receiving home health services. The primary ICD-10-CM diagnosis code reported assigns the patient into one of 12 clinical groupings (e.g., neuro rehabilitation, wounds, behavioral health, etc.).
    • Secondary diagnosis(es): These comorbid conditions can affect patient care and are also factored into the payment.
  • Functional Impairment: The functional impairment of the patient (i.e., low, medium, high) is factored in using eight Outcome and Assessment Information Set (OASIS) items related to Activities of Daily Living (ADL). A higher functional impairment level will qualify for a higher payment rate.
  • Reporting periodCare is based on a period of 30 days instead of 60 days.
  • Therapy thresholds removedWith the elimination of the therapy caps, this information no longer factors into the payment.
  • Low Utilization Payment Adjustment (LUPA) revisedThe old system threshold for LUPA was set at five visits during a 60 day period. Under the new system, LUPA is based on the case-mix group (see below) and can range from two to six visits during a 30 day period depending on the group.

Case-Mix Adjusted Payment Group: The following variables are used to calculate the patient’s case-mix adjusted payment group: 

  1. Locationgeographic location where patient care is provided
  2. Admission Source institutional (acute or post-acute care provided within 14 days prior to admission) or community (no acute or post-acute care)
  3. Timingearly (first 30-day period of care) or late (subsequent 30-day period[s])
  4. Clinical Grouping: based on the primary diagnosis
  5. Functional Impairment Level: from OASIS items
  6. Comorbidity Adjustment: based on the secondary diagnoses

Like the RVU for outpatient services, the weight computed by the case-mix is multiplied by a factor (think conversion factor for RVUs) to arrive at an estimated monthly payment.

Medicare Home Health Payment Calculator for 2020

If this sounds complicated, well, it can be. To help home health agencies make this transition, Find-A-Code has a PDGM payment calculator for home health coming soon. All you need to do is fill out the simplified form with the applicable patient information and click the [submit] button. It’s easy, fast, and accurate.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association