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CGS Overview: Home Health Patient-Driven Groupings Model (PDGM)

Effective for claims with a “From” date on or after January 1, 2020, Change Request (CR) 11081 implements the policies of the home health Patient-Driven Groupings Model (PDGM) as described in the Calendar Year (CY) 2020 home health (HH) final rule (CMS-1711-FC ). The PDGM changes the unit of payment from 60-day episodes of care to 30-day periods of care and eliminates the therapy thresholds used in determining home health payment.

Implementation
For 60-day episodes that begin on or before December 31, 2019, and span January 1, 2020, the payment will be the calendar year (CY) national, standardized 60-day episode payment amount.

For HH periods of care that begin on or after January 1, 2020, the unit of payment will be the CY 2020 national, standardized 30-day payment amount.

Under PDGM, recertification for home health services, updates to the comprehensive assessment and updates to the HH plan of care continue on a 60-day basis.

Resources:

This page includes the following information (click the title to access):

Home Health Prospective Payment System (HH PPS) vs PDGM
Claim Filing Elements
Health Insurance Prospective Payment System (HIPPS) Code
Low Utilization Payment Adjustment (LUPA)
Partial Payment Adjustment
Outlier Payment

Home Health Prospective Payment System (HH PPS) vs PDGM

What’s Changing

HH PPS

PDGM Effective January 1, 2020

Request for Anticipated Payment (RAP)

Home health agency (HHA) providers submit one RAP and one final claim for each 60-day episode.

Split Percentage Payment:

First 60 day episode of care is 60/40
Subsequent episodes are 50/50

HHA providers submit one RAP and one final claim for each 30 day period.

Split Percentage Payment:

Initial and subsequent period of care will be 20/80

Newly Enrollment HH Providers
HHA providers newly enrolled in Medicare on or after January 1, 2019, submit a no-pay RAP and one final claim for each 30 day period.

Auto Canceled RAPs

If the claim is not received 120 days after the start date of the episode or 60 days after the paid date of the RAP (whichever is greater), the RAP payment will be canceled automatically by FISS and will be recouped.

FISS will be modified to auto-cancel RAP payments on or after January 1, 2020 when the final claim is not received within 90 days of the statement FROM date of the RAP, or 60 days from the paid date of the RAP.

Episode of Care / Timing

Early episode of care - First two 60-day episodes in a sequence of adjacent covered episodes.

Late episode of care – Third episode and beyond in a sequence of adjacent covered episodes.

Two period timing categories used for grouping a 30-day period of care.

Early period of care - First 30-days

Late period of care - Second or later 30-day period

Admission Source

Not used in HH PPS

Two admission source categories used for grouping a 30-day period of care.

Institutional:

Any acute or post-acute (inpatient, skilled nursing, inpatient rehabilitation facility, long term care hospital, inpatient psychiatric facility) care in the 14 days prior to the HH admission

Community:

No acute or post-acute care in the 14 days prior to the HH admission.

Optional reporting of new Occurrence Codes 61 and 62 identifies the admission source.

Therapy

Number of therapy visits:

0 to 13 visits
14 – 19 visits
20+ visits

Therapy thresholds eliminated.

Home Health Resource Groups (HHRGs)

Case-mix adjusted payment for 60 day episode is made using one of 153 HHRGs based on severity levels.

Clinical
Functional
Service utilization

Case-mix adjusted payment for a 30 day episode is made using 432 possible groups

Admission Source (Institutional or Community)
Timing (early/late)
Clinical Grouping (principal diagnosis on claim)
Functional Impairment Level (OASIS items)
Comorbidity Adjustment (secondary diagnoses on claim)

Health Insurance Prospective Payment System (HIPPS) Code

Position 1 – Timing (early/late) therapy threshold
Position 2 – Clinical Domain
Position 3 – Functional Domain
Position 4 – Therapy utilization
Position 5 – Non-routine supplies

Position 1 – Timing/Admission Source
Position 2 – Clinical Group
Position 3 – Functional Level
Position 4 – Comorbidity
Position 5 – Placeholder

HHAs may submit the HIPPS code they expect will be used for payment if they run grouping software. If not, they may submit any valid HIPPS code. Grouping to determine the HIPPS code used for payment will occur in Medicare systems and the submitted HIPPS code on the claim will be replaced with the system-calculated code.

See the Health Insurance Prospective Payment System (HIPPS) Code section on this Web page for additional information.

LUPA

Four or fewer visits for entire episode

Each of the 432 case-mix group has a threshold to determine if the period of care would receive a LUPA. This threshold is determined by the tenth percentile of visits in each payment group with a minimum of threshold of 2.

Claim Filing Elements

The following claims filing elements are new under the PDGM.

Occurrence Code (OC)

50 (required)

Report the OASIS assessment completion date by submitting OC 50 and the OASIS item MO090 date on the final claim

61 (optional)

Report OC 61 to indicate an acute care hospital discharge within 14 days prior to the From date of any HH claim. (See Note below.)

62 (optional)

Report OC 62 to indicate a SNF, IRF, LTCH, or IPF discharge within 14 days prior to the Admission date of the first HH claim. (See Note below.)

NOTE: If OC 61 and 62 are not present, Medicare systems will use inpatient claims history to assign Institutional payment groups based on the most current information.

Treatment Authorization Code
The treatment authorization code, which is reported under HH PPS in the TREAT. AUTH.CODE field on the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE), Claim Page 05, is no longer required. This field will only be used when required by the pre-claim review process when it actually represents an authorization number.

Principal and Other Diagnosis Code
The principle and other diagnosis ICD codes on the claim will be used for payment grouping rather than the OASIS item. As a result, the claim and OASIS diagnosis codes will no longer be expected to match in all cases. When diagnosis codes change between one 30-day claim and the next, HHAs are not required to complete an ‘other follow-up’ (RFA 05) assessment. However, an ‘other follow-up’ (RFA 05) assessment is required when such a change would be considered a major decline or improvement in the patient’s hearth status. Refer to the MM11272 for additional information.

Health Insurance Prospective Payment System (HIPPS) Code

After January 1, 2020, under the Patient-Driven Payment Model, a case-mix adjusted payment for a 30 day period of care is made using one of 432 home health resources groups (HHRGS). On Medicare claims, the HHRGs are represented as Health Insurance Prospective Payment System (HIPPS) Codes. The distinct 5-position, alphanumeric home health HIPPS codes are created as follows:

First Position - a numeric value representing a combination of the referral source (community or institutional) and the period timing (early or late).
Second and Third Positions - represent the clinical and functional domains of the HHRG coding system.
Fourth Position - represents the co-morbidity category that applies to the patient.
Fifth Position - a placeholder for future use, required only because the field used to report HIPPS codes requires five positions.

Position #1

Position #2

Position #3

Position #4

Position #5

Source & Timing

Clinical Group

Functional Level

Co-Morbidity

Placeholder

1 - Community Early

A - MMTA Other

A - Low

1 - None

2 - Institutional Early

B - Neuro Rehab

B - Medium

2 - Low

3 - Community Late

C - Wounds

C - High

3 - High

4 - Institutional Late

D - Complex Nursing Interv.

E - MS Rehab

F – Behavioral Health

G – MMTA Surgical Aftercare

H – MMTA Cardiac & Circulatory

I – MMTA Endrocine

J – MMTA GI/GU

K – MMTA Infectious Disease

L – MMTA Respiratory

Using this structure, a second period for a patient with a hospital inpatient stay during the period (institutional late), in the Wounds group, high functional severity and no co-morbidity would be coded 4CC11. HIPPS codes continue to be reported with revenue code 0023.

Low Utilization Payment Adjustment (LUPA)

For periods of care beginning on or after January 1, 2020, if an HHA provides fewer than the threshold of visits specified for the period’s HHRG, they will be paid a standardized per visit payment instead of a payment for a 30-day period of care. Under PDGM each of the 432 case-mix groups has a threshold to determine if the period of care would receive a LUPA. This threshold is determined by the 10th percentile of visits in each payment group with a minimum threshold of 2

Partial Payment Adjustment

A partial payment adjustment will apply if a beneficiary transfers from one HHA to another, or is discharged and readmitted to the same HHA within 30 days of the original 30-day period start date. The adjustment is pro-rated based on the length of the 30-day period ending in transfer or discharge and readmission, resulting in a partial period of payment.

Outlier Payment

When cases “lie outside” expected home care experience by involving an unusually high level of services in 60-day episodes under HH PPS, or 30-day periods of care under PDGM, Medicare claims processing systems will provide extra or “outlier” payment. Outlier payments can result from medically necessary high utilization in any or all of the service disciplines.

Posted: 11.25.19