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Cms Pdgm Interactive Grouper Tool

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Brent Mccoy
• Wednesday, 16 December, 2020
• 20 min read

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.

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Contents

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. End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA).

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement.

This product includes CPT which is commercial technical data and/or computer databases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer databases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of Dears 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of Dears 227.7202-1(a)(June 1995) and Dears 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurement and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurement.

The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied.

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In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. BY CLICKING BELOW ON THE BUTTON LABELED “I ACCEPT”, YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

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Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services.

The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS ; and no endorsement by the ADA is intended or implied. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4.

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CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

Instead, you must click below on the button labeled “I DO NOT ACCEPT” and exit from this computer screen. 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: Signing Up for Beta Testing Each update of the Home Health Grouper software will be available for beta testing approximately 8-10 weeks prior to the implementation date.

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.

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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.

CLSPD Revised Manual Instructions for Claims Processing Transmittal 4452. Details: CMS offers a list of them on its CY 2020 PDGMGrouperTool 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.

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A list of all ICD-10 codes and their correlating clinical groupings is available on the CMS website under the PDGMGrouperTool. 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.

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This interactive training tool is designed to help you learn how different factors generate the payment resource groupers under PDG. The tool is not tied to any patient, so each variable that impacts payment can be adjusted to give you targeted insights into how you can collect maximum reimbursement under PDG.

Defined by the principal diagnosis reported on home health claim Twelve total groups used in the PDG Access warns agencies to not enter unpayable codes throughout the software (starting at patient intake).

A comorbidity is defined as a medical condition coexisting in addition to a principal diagnosis. Comorbidity is tied to poorer health outcomes, more complex medical need and management, and higher care costs.

PDG includes a comorbidity adjustment category based on the presence of secondary diagnoses. Low comorbidity adjustment : There is a reported secondary diagnosis that is associated with higher resource use.

When a secondary diagnosis that represents a comorbidity adjustment is entered, then a low or high indicator will appear. Resource use is regressed on the seven OASIS items (along with other covariance from each of the PDG groups).

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Admission Source Timing Clinical Grouping Functional Impairment Level Comorbidity Adjustment To select other responses for a new case-mix, simply start entering different information for each section.

Using historical OASIS and visit information, this analysis assesses the impact of PDG on revenue, based on past episodes. The user will then be able to view the PDG Revenue Impact Analysis in the following locations.

As you review your report, it will be immediately apparent how the questionable primary diagnosis encounter codes (which are not payable under PDG) will financially impact your business. Preparing for these coding practices will have the greatest impact toward achieving success under PDG.

There are multiple tool tips included in the report to guide you through the information. The report looks at the expected payment amounts for episodes within the selected year chosen for patients with an OASIS Discharge, Recertification, Resumption of Care, Transfer to Inpatient Facility, or Transfer Discharge.

Information for 2019 includes financial data as of the last updated date, which is adjusted at the beginning of each month. Includes the percentage and number of questionable episodes where primary diagnosis codes that are not groupable under PDG were used.

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Identifies how much revenue was billed under the current PPS billing system using questionable primary diagnosis codes and the dollar amount reflecting codes that will not be billable in January 2020 under PDG. The Home Health solution gives a warning when questionable codes are entered into the system at intake and on completion of the OASIS assessment.

Includes the percentage of PPS episodes and the amount or revenue billed. Overall, Access clients have an average of 14% of episodes containing at least one Luna payment period.

The Home Health solution identifies Lucas for each 30-day payment period in the PDG Case-Mix Analysis Report. This section identifies diagnosis types commonly used by your agency and the corresponding clinical groupings.

Questionable encounter codes are not listed in the Clinical Groupings, since they are not groupable. This system enhancement enables you to decide at intake if a patient is eligible for home health services and protects your revenue for the care your agency provides.

An overview of updates made to the intake forms in preparation for PDG is provided below: Admission Source and Timing have been added to the intake process in preparation for PDG.

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This information will be the basis of several reports and PDG projection tools at intake. When your agency receives a questionable encounter diagnosis code, query the referring physician for more specific information, to identify a more appropriate diagnosis code under PDG and update the face-to-face information.

If the patient’s insurance group will not be impacted by PDG, you can clear the warning message and proceed. Selecting a face-to-face encounter option is now required in the Home Health solution.

Date of Face-to-Face Visit Select when the physician encounter documentation for the primary diagnosis has been received. The date will flow to the Plan of Care to ensure compliance for certification.

If the provider fails to make a selection by September 15th, they will automatically be place in Choice 2: Post payment Review. The MAC sends ADR's and follows CMS post payment review procedures.

No details have been released on the percentage of Illinois Has that did not make a selection and were placed automatically into Choice 2. In next week’s issue of News Bites, HCA will announce details on a free webinar reviewing your Review Choice options in greater detail as well as information on how to register for the Palmetto GBA services portal, which providers must use in order to make their selections.

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HCA will also be partnering with Palmetto GBA to deliver an RCD Post Implementation Session on October 23rd, in Cleveland, Ohio, taking best practices from the Illinois demonstration. For more information about your choice selection prior to our webcast, please see the links below or contact Erin Begin.

Starting on August 1, 2019 (Phase 2), the Mylar Ohio Plan (Cop) will send a non-compliance notice to providers. If the provider does not come into compliance by the allotted time, the Mylar Ohio Plan will substantiate the violation of the Mylar Waiver Provider Signature Requirement and submit the referral to ODM mailbox.

Beginning on November 1, 2019 (Phase 3), ODM will issue Notices of Operational Deficiencies. ODM will continue to sanction for failure to comply which could include termination of their Medicaid Provider Agreement.

HCA will be reaching out to various national software and Medicare Advantage vendors over the coming months to determine which will be moving to the PDG payment methodology. Aetna Better Health of Ohio has confirmed that they intend to use PDG reimbursement for Medicare covered services with the implementation.

As a reminder, providers can access the InteractiveGrouperTool on CMS ’s Home Health Patient-Driven Groupings Model website. Eve Webinars Scheduled to Help Providers with San data System Set Up Debbie Jenkins Earlier this week, ODM shared that the Eve Provider Hotline is experiencing extended wait times with the Phase Two implementation date set for Monday, August 5.

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An important deviation from that proposed rule relates to the changes to the hospice election statement. Instead of an October 1, 2019, effective date, CMS has issued an effective date of October 1, 2020, to allow time for additional consideration of operational issues resulting from the changes and for CMS to develop a model election statement.

In addition to a required statement that there could be some necessary items, drugs or services not covered by the hospice because the hospice has determined it to be unrelated to the terminal diagnosis, there is a required notification of the beneficiary’s right to request an addendum of a list of those services and rationale for the non-covered items. Instead of the proposed 48-hour turnaround time for the addendum, the final rule gives providers 5 calendar days to provide if requested at the time of election, or 72 hours if requested during the course of hospice care but after the election of hospice.

Rebasing of continuous home care, inpatient respite care, and general inpatient rates; with a slight change to proposed rates on each level of care Reduction of the routine home care payments by 2.72% Annual base payment rate increase of 2.6% Elimination of the 1-year lag in use of the hospital wage index starting in FY2020 Aggregate Cap update to $29,964.78 Updates to the Hospice Quality Reporting Program (ARP), including changing of the standardized assessment tool from HEART to HOPE, or Hospice Outcomes and Patient Evaluation. HCA will continue to review the final rule and will provide further details and information in the next week.

Supplemental Medical Review Contractor Posts Hospice Project Erin Begin Meridian, the Supplemental Medical Review Contractor (SRC) for the Centers for Medicare & Medicaid Services (CMS), has posted a second project targeting hospices. The second phase of this project will focus on hospices services (not on a particular level of care) provided in the ALF.

CMS also proposes that the PA must be the patient’s attending physician, and that he or she may not have an employment or contractual arrangement with the hospice.” Resource New EFT Vendor, ECHO Erin Begin On July 26, Resource Ohio announced that it was partnering with a new Electronic Funds Transfer (EFT) vendor, ECHO Health Inc., in an effort to increase payment frequency of payments to providers.

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Resource Releases Assisted Living, Home Health and Hospice Billing Guidance Erin Begin On July 31, Resource Ohio provided an update for Mylar Ohio providers relating to an increase in incorrect billing for Assisted Living, Home Health and Hospice Services. This change is based on the Jan. 2019 update Molina made to the authorization and claim reconsideration processes.

Specifically designed for Home Health nursing case managers, team leads and Administrators, this conference will provide direction on best practices for successful PDG therapy integration, optimizing interdisciplinary OASIS collaboration, utilizing administrative staff for high risk patients and utilization review, the application of front loading specific diagnosis groups, clinical strategic scheduling and much more! Join HCA and Health PRO Heritage in Columbus, Ohio on September 12th and 13th for this two-day comprehensive conference specifically geared towards nursing.

This program offers up to 11.5 hours of continuing education credit for Administrators, Nurses and Czechs. For more information on other offerings and programs presented during our Nursing Conference, please visit the Effect website.

HCA Partners with Palmetto GBA on RCD Post Implementation Session Erin Begin Home health providers in Illinois and Ohio are gleaning insights from the implementation of the Review Choice Demonstration, with Ohio providers live beginning September 30th, 2019. During this presentation on October 23rd, 2019 in Cleveland, OH, Palmetto GBA's CJ Sims and Charles Canaan will focus on the RCD program and selection process through the service portal.

Our session will include lessons learned from the implementation of the RCD program in Illinois on June 1st, the top errors resulting from those RCD submissions, and common issues that users experienced in using the Palmetto GBA services portal. HCA HH Proposed Rule CY2020 Webinar Recording Available Erin Begin HCA recently hosted a webinar to discuss the many changes of the recently issued Home Health Proposed Rule for Calendar Year 2020.

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We detailed which items require more immediate attention and review, operational specific impacts, and shared industry insight on applicability to the timing of the PDG release and training, recently taken from National leaders at the Home Health Financial Managers Conference in Chicago, IL. Although this rule is proposed, and not final, there are some changes which warrant additional review and possible operational impact analysis, such as the revised case mix for the clinical groupings.

HCA Members can access the webinar and slides here, under Current Changes> Home Health Proposed Payment Rate Update Rule CY2020. The compilation is provided by Drew Vogel, CNH, FAC HCA, a long-time HCA member with nearly 30 years’ experience as an administrator.

The program is also intended to provide good news opportunities for use in local and statewide markets. You will need to be logged into the site with your username and password before you attempt to post a position.

Individuals will be added to the email listing for all of HCA's High electronic bulletins and publications Details: The National Association for Home Care & Hospice (NAC) has developed a suite of resources for physicians interested in learning more about the Patient-Driven Groupings Model (PDG).

Despite the ample runway, many home health providers are seemingly still adjusting their therapy strategies, prolonging the initial layoffs, pay cuts and furloughs that took place at the beginning of the year. PDG, implemented on January 1, 2020, is revolutionizing the payment methodology for all Medicare Home Health Agencies in the United States.

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We’ve developed several education tools you need to ensure your agency will make a smooth transition. Details: The PDG, or Home Health PPS Grouper Software (Hogs), relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories and eliminates the use of therapy service thresholds.

Details: PDG does not change the certification requirements for home health services. A F2F encounter that is related to the primary reason for home health services will continue to be required in order for Has to bill for care.

Details: Home Health Solutions sells a PDG Decision Tree in its online store to help agencies with the decision-making process. Our tool captures the decision-making process in a simple, easy-to-follow format which you can easily share with your staff members.

Details: Private duty has often flourished in times when home health and other parts of the care continuum struggle. While PDG is ultimately projected (long-term) to increase payments in the home health space, growing pains along the way may create opportunities for other non-medical care providers who can assist in a supporting role.

Details: The Patient-Driven Groupings Model (PDG) is the biggest change to home healthcare in decades. Access is your trusted partner to help you prepare for, navigate, and thrive in this changing environment.

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Details: From the monumental Patient-Driven Groupings Model (PDG) and the unexpected pre-payment phaseout to the expanding Review Choice Demonstration (RCD), 2019 was a whirlwind year for the home health industry. Details: The PDG Analytics Tool points out the drivers of any changes in reimbursement so that the agency can adapt processes accordingly and in a compliant manner.

... skilled nursing facilities, outpatient clinics and home health and hospice care settings. Details: Home Health Payment Tools As of January 1, 2020, the Centers for Medicare & Medicaid Services (CMS) is changing how Medicare reimburses for home health services.

The new Patient-Driven Groupings Model (PDG) is more complex than the previous prospective payment system. Details: When the Centers for Medicare & Medicaid Services (CMS) begins reimbursing home health agencies for services using the Patient-Driven Groupings Model (PDG), it will have a dramatic impact on agency operations from intake through discharge.

Arguably, the biggest potential threat to an agency’s bottom line once PDG replaces the Home Health Prospective Payment System (HH PPS) on Jan. 1, 2020 ... Details: The Patient-Driven Groupings Model (PDG) is in full effect and is already bringing sweeping changes to the way the home health industry is approaching care.

SHP has been working hard to provide the tools that will help you understand performance, increase efficiency, and maximize margin under the new payment model. There is a Facebook group page set up for providers to talk about all things PDG -related.

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Details: SPOTLIGHT ON Home Health Guide to OASIS-D1: A Reference for Field Staff. Authored by CEO, Melinda A. Gabor, this brand-new pocket guide provides a quick reference for filling out the OASIS, with tips and callouts on new items, including which items affect PDG case mix, rating, and value-based purchasing reimbursement.

Details: Find a PDG Resource Partner that Knows Home Care. This new methodology is complex and brings significant change for home health agencies impacting nearly all aspects of operations.

Details: Home Health Care agencies are continually faced with changing regulations such as PDG. Details: Last fall, the National Association for Home Care and Hospice asked 1,500 agencies how practices would change under PDG.

Details: As home health providers know, low-utilization payment adjustments (Lucas) can have a detrimental impact to an agency both clinically and financially. Beginning January 1, 2021, home health agencies (Has) will be required to submit a Request for Anticipated Payment (RAP) before filing each claim.

Details: Go to Upcoming Event List : The PDG Summit has sold out for both March 12 & 13, please join the wait list if interested in attending if a spot becomes available: Join the Wait List Here The Home Care Alliance of MA will co-sponsor with the National Association for Home Care & Hospice (NAC), the Forum of State Associations, and the Home Health Financial Management Association, a PDG ... Details: Healthcare Strategies (HCS) is a home health and hospice support agency, providing EMR back office and point of care software, outsourcing for billing and collections and Coding and OASIS Review, and consulting, management and education services to clients throughout the United States.

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