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PDGM Admission Source 14 Day Calculator

Under the Home Health Patient Driven Groupings Model (PDGM), there are two occurrence codes that home health agencies should report to support the admission source category of the PDGM (Community vs. Institutional).  Only one of these occurrence codes should be reported on a single claim.  If both codes are reported, the claim will be sent to the Return to Provider (RTP) file.  Use the 14-day calculator below to determine the period in which occurrence code 61 or occurrence code 62 should be submitted to support the admission source, community or institutional.

In situations where there are two inpatient discharges during the 14-day period, report the later discharge date. 

In situations where you are not aware of an inpatient discharge within 14-days of an admission, if Medicare has received an inpatient claim, the Medicare system will recognize the discharge claim during processing and will group the claim into an institutional payment group based on claims history information.  If Medicare has not received an inpatient claim, meaning that neither you nor Medicare is aware of an inpatient discharge, the claim will be paid using a community payment group.  Note that if an inpatient claim comes in later, Medicare systems will automatically adjust the paid home health claim and pay using an institutional payment group instead.



Hospital Discharge Date

Report OC 61 on admission claims and continuing claims, if applicable, to indicate the “Through” date of an acute care hospital discharge within 14 days prior to the “From” date of the HH claim.

Claims with hospital discharges within 14 days are grouped into “Institutional” payment groups.

Other Institutional Discharge Date

Only reported on admission claims (e.g., claim “From” and “Admission” date match).  Report OC 62 to indicate the “Through” date of a skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), long term care hospital (LTCH), or inpatient psychiatric facility (IPF) discharge within 14 days prior to the “From” date of the first HH claim.

Admission claims with other institutional discharges within 14 days are grouped into “Institutional” payment groups.

"From" date of your claim:

Disclaimer: CGS' online tools and calculators are informational and educational tools only, designed to assist suppliers and providers in submitting claims correctly. CGS makes no guarantee that this resource will result in Medicare reimbursement for services provided. Although we've made every reasonable effort to provide effective resources, CGS is not responsible for the consequences of any decisions or actions taken in reliance upon or as a result of the information that these tools provide. CGS is not responsible for any human or mechanical errors or omissions.


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