In conjunction with the implementation of the PDG, there will be a change in the unit of home health payment from a 60-day episode to a 30-day period. Archived versions of the Home Health Prospective Payment System (HH PPS) Grouper are available for download.
The HH PPS Grouper software will only work for OASIS submissions with an assessment completion date from through December 31, 2019. Included in the v02.1.21 HH PPS Grouper software update are the FY 2021 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes, effective beginning January 1, 2021.
Implementation of New International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Diagnosis Codes, Effective April 1, 2020: Both U07.1, COVID-19 and U07.0, Vaping-related disorder are assigned to the Medication Management, Teaching and Assessment-Respiratory (MMTA-Respiratory) clinical group for purposes of case-mix adjustment under the HH PPS.
The PDG relies more heavily on clinical characteristics, and other patient information to place home health periods of care into meaningful payment categories. One case-mix variable is the assignment of the principal diagnosis to one of 12 clinical groups to explain the primary reason for home health services.
In May 2017, CMS released an Advanced Notice of Proposed Rule making (AN PRM) which outlined a new case-mix model, the Resident Classification System, Version I (RCS-I), that would be used to replace the existing RUG-IV case-mix model, used to classify residents in a covered Part A stay into payment groups under the SNF PPS. Below are several items we have posted concurrent with the FY 2019 SNF PPS Norm to assist stakeholders in reviewing and commenting on the proposed PDP.
For a subset of these ICD-10-CM diagnosis codes, the clinical category will be modified if there were specific related surgical procedures performed in the hospital stay immediately preceding admission to the skilled nursing facility. The surgical procedure code lists provided will be used as a reference by the skilled nursing facility staff to augment the resident’s clinical category classification.
The staff would review the information sent by the preceding hospital stay to identify any procedures defined in these surgical clinical categories. To assist stakeholders in understanding the process by which SNF residents would be classified into PDP payment groups, we are providing three files.
The first file provides a narrative step-by-step walkthrough that would allow stakeholders to manually determine a resident’s PDP classification based on the data from an MDS assessment. Stakeholders should use these revised SNF PDP files (Version 2) to inform their comments on the proposed rule.
In the second phase of the project, which is now in process, the contractor is using the findings from this Base Year Final Summary Report as a guide to identify potential models suitable for further analysis. Acumen hosted a third Technical Expert Panel in June 2016 to provide an outline of basic payment structure for a revised SNF PPS, including the various new components of the revised SNF PPS and a discussion of potential pricing schedules which may be incorporated.
Acumen hosted a fourth Technical Expert Panel in October 2016 to provide an outline of the recommended alternative payment model for a revised SNF PPS, including the various new components of the revised SNF PPS and a discussion of potential pricing schedules which may be incorporated. Based on the work conducted by Acumen during the second phase of the project, which included substantial feedback from stakeholders and four Technical Expert Panels, the contractor drafted a Technical Report (PDF), which discusses the research conducted by the contractor on developing an alternative to the existing methodology used to pay for services under the SNF PPS.
To assist stakeholders in their review of the RCS-I model, as discussed in the SNF PPS Advance Notice of Proposed Rule making (AN PRM) and Technical Report provided above, we are providing a provider-specific impact analysis file, which details the estimated impact of the RCS-I model discussed in the AN PRM on Medicare Part A payments to each SNF in the country. This file provides a step-by-step walk-through that allows stakeholders to manually determine a resident’s RCS-I classification based on the data from an MDS assessment.
This document should be used in conjunction with the discussions found in the AN PRM and accompanying Technical Report to better understand the process for resident classification under RCS-I. The contractor is continuing with further refinements and considering potential improvements to the overall SNF PPS payment structure, and we welcome your comments and feedback.
This version 5.00 Final, effective October 1, 2020, replaces the v5.00 Beta posted previously. This second beta release addresses the issue encountered by Vent era in regard to error code 9.
A Beta test release of CMG version 5.00 is now available to assist providers and vendors in the transition of the program from DLL to Java JAR. The prior CMG and DLL Versions were both 4.01, allowing processing of IRFA assessments with discharge date on or after 4/1/2020.
It uses the Quality Indicator items, incorporates an unweighted motor score calculation, contains revised case-mix groups, and updates the ICD-10-CM codes used by the CMG grouper. NOTE: During the beta testing, there were errors in the DLL for low motor score values documented in Appendix E. These errors were corrected for the final release.
This new version incorporates revisions to the list of comorbidities used by the CMG grouper. This new version incorporates revisions to the list of comorbidities used by the CMG grouper.
This new version incorporates a correction to the handling of comorbidities by the CMG grouper. The test data files posted with the original CMG 2.81 package are flawed.
Comorbidity Tier assignment is made on the basis of the presence of specific single ICD-10-CM diagnosis codes and on the basis of specific ICD-10-CM code combinations. The only changes with the final version of CMG 2.70 (from the previous draft version) is to remove the word “Draft” from the file names and documentation headers of “Technical documentation.pdf” and Program documentation.pdf”.
The major change with draft version of CMG 2.70, from the current version CMG 2.60, is to accommodate the expansion of the comorbidities (Item 24 on the IRFA) from a maximum of 10 ICD-9 codes to a maximum of 25 ICD-9 codes. CMG V2.70 Corrected XML Test Data (ZIP) : In the XML test data included with the CMG 2.70 package, an incorrect format has been used for Item 24 comorbidities that are skipped.
The data specifications require a skipped comorbidity to be coded as a single caret but the test data has been coded as a caret with trailing blanks . These errors have been corrected in a new XML test data file (CM1F15V9 xml.zip) now available for download.
The update adds a third item explaining XML test data problems and the corrections made. Details: For additional information, refer to section 40.1 of the Medicare Claims Processing Manual (CMS Pub.
10) Use this tool to prevent your RAP for periods of care that begin on or after January 1, 2020, from being auto-cancelled by the Fiscal Intermediary Standard System (Fish). Details: One mechanism guaranteed to help all home health agencies prepare for PDG is CMS ’s interactive grouper tool, which calculates agencies’ expected payments under the new model, Miller said.
Though some experts have doubted the grouper tool ’s accuracy, at the very least, it provides agencies a place to start. Details: CMS will use the PDG to reimburse home health agencies.
• Consider a certified coder/coders on your intake/marketing team to cut down time spent running around to clarify and correct. Details: Details: The PDG Analysis Tool by Simone Healthcare Consultants will provide a clear view of what is coming and what to do to effectively handle the specific circumstances in your home health organization.
Details: Home Health Patient-Driven Groupings Model | CMS Details: The PDG relies more heavily on clinical characteristics, and other patient information to place home health periods of care into meaningful payment categories. Overview In July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDP), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay.
Details: New Home Health Patient-Driven Groupings Model (PDG) Tool. Health Details: To help you determine the visit threshold, the Home Health Low Utilization Payment Adjustment (Luna) Threshold Calculator was developed based on the CMS CY 2020 PDG Case Mix Weights and Luna Thresholds. Simply enter the Hips code, click Search, and the therapy visit threshold will display.
Details: A lot has been written about PDG, the new home healthcare Patient-Driven Groupings Model first proposed by the Centers for Medicare & Medicaid Services (CMS) in July 2018. CMS released the final rule on October 31, 2018, and PDG will become effective on or after January 1, 2020.
CMS PDG Revised Manual Instructions for Claims Processing Transmittal 4452. Details: CMS offers a list of them on its CY 2020 PDG GrouperTool page (Download the file and look for the ICD-10 DNS Excel spreadsheet).
PDG + COVID-19 changed the home health landscape dramatically this year! Tack on CMS release of the 2021 Home Health Final Rule on October 29, and we recognize that agencies may be struggling to navigate reimbursement regulations, declining caseload volumes, staff anxieties/shortage & more.
A list of all ICD-10 codes and their correlating clinical groupings is available on the CMS website under the PDG GrouperTool. If the primary code does not match this list, CMS will not be able to assign the 30-day period to one of the six PDG clinical groups, and will likely return the claim to the provider ...
“Take to whoever is doing your coding and tell them, ‘Do not, as of today, send me one more plan of care or one more OASIS or one more claim that has a primary diagnosis that is not on this list ... Details: CMS is now only showing the 43,287 acceptable codes in their GrouperTool under the “ICD10 DNS” excel tab.
Details: On August 21, 2019, CMS had a Home Health Patient Driven Groupings Model Operational Issues Call. Health Details: This document provides PDG transition guidance including OASIS time point, data set version and M0090 Date Assessment Completed considerations for patients where resulting assessments must provide the Health Insurance Prospective Payment System (Hips) code for a PDG payment period that begins January 1, 2020, or later ...
Details: To assist home health providers in determining reimbursement for Medicare home health PPS/PDG claims, Palmetto GBA offers providers the ability to estimate their claims payment amount online. The online calculator is designed to estimate the amount of reimbursement for all types of Medicare HHA claims with service episodes/periods beginning on ...
Details: PDG Impact on Your Agency: A Simplified Tool Posted on November 1, 2018, July 30, 2019, by Jazz Associates Last month we encouraged you to access the information that CMS has provided to learn the potential impact of the Patient-Driven Groupings Model (PDG) on your agency. Details: There, operators can find a list of all 43,278 primary diagnoses acceptable under PDG.
You can find the updated file in the Downloads section of the MDS 3.0 webpage. Navigating health reform Update: 8/22/2020 Our 2021 PDP rate listing and calculator is now available.
CMS also finalized a sub-regulatory process for updating ICD-10-CM codes used for PDP patient classification. Download the Calculator CLA can assist you with PDP readiness assessments, training of clinical, coding, and management staff, and therapy contract renewals.