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. Section 1886(d) of the Act specifies that the Secretary shall establish a classification system (referred to as Dogs) for inpatient discharges and adjust payments under the IPS based on appropriate weighting factors assigned to each DRG.
Therefore, under the IPS, we pay for inpatient hospital services on a rate per discharge basis that varies according to the DRG to which a beneficiary's stay is assigned. Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption.
Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least annually. Currently, cases are classified into Medicare Severity Diagnosis Related Groups (Madras) for payment under the IPS based on the following information reported by the hospital: the principal diagnosis, up to 24 additional diagnoses, and up to 25 procedures performed during the stay.
In a few Madras, classification is also based on the age, sex, and discharge status of the patient. Effective October 1, 2015, the diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS).
For additional information on the MS-DRG system, including yearly reviews and changes to the Madras, please view prior Inpatient Prospective Payment System (IPS) proposed and final rules located in the left navigational area of this page. CMS is hosting a listening session that will describe the Medicare-Severity Diagnosis-Related Group (MDR) Complication and Comorbidity (CC)/Major Complication and Comorbidity (MCC) Comprehensive Analysis discussed in the FY 2020 Inpatient Prospective Payment System (IPS) proposed and final rules.
This listening session will include review of the methodology to measure the impact on resource use and will provide an opportunity for CMS to receive public input on this analysis and to address any clarifying questions in order to assist the public in formulating written comments on the current severity level designations for consideration for FY 2021 rule making. For additional information regarding the Version 38 Test GROUPER please see the file titled CMS -1735-P Table 6P.1a below.
The 21st Century Cures Act requires that by January 1, 2018, the Secretary develop an informational “Hopes version” of at least 10 surgical Madras. Under the Hopes version of the Madras developed for this requirement, to the extent feasible, the MS-DRG assignment for a given service furnished to an outpatient (billed using a Hopes code) is as similar as possible to the MS-DRG assignment for that service if furnished to an inpatient (billed using an ICD-10-PCS code).
The HCPCS-MS-DRG definitions manual and software developed under the requirements of section 15001 of the 21st Century Cures Act (Public Law 114–255). 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.
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. CMS also released a new ICD-10 Medicare Severity-Diagnosis Related Group Grouper software package (Version 37.2) to accommodate the new codes, effective for discharges on or after Aug. 1.
This video tutorial is approximately 22 minutes in length and is designed to provide targeted guidance for accurate coding using live-action patient/resident scenarios. Read more The Resident Assessment Validation and Entry System (raven) was developed by the Centers for Medicare & Medicaid Services (CMS).
The Bra PDP Grouper Calculation screen (for states requiring PDP scores on Bra comprehensive NC & No assessments) was updated to allow for entry of an End Date to go up through 12/31/2099 The updates included with raven 1.7.4 (MDS Item Set v1.17.2, Data Specification Errata v3.00.5, the MDS VUT v3.4.0) Read more An update to the PDP Grouper DLL has been posted, along with its source code and test cases.
This version, V1.0008, corrects an issue with a dynamic array that was not consistently reinitialized when processing multiple assessments within a short time frame. It is important to include the control item STATE_PDPM_OBRA_CD (as defined in the V3.00.5 errata for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications) for assessments with target date on or after October 1, 2020.
Note that this FINAL version supports the ICD-10 codes that are defined in the data specifications as valid for item I0020B for FY2021. Also, please note that the grouper expects valid FY2021 ICD-10 codes for I8000A-J when processing assessments with target date on or after October 1, 2020.
“The key to efficient PDP internal audits during a COVID-19 outbreak or any crisis is focus,” says Robin Hillier, CPA, TNA, LNA, RAC-MT, president of Rah Consulting in Westerville, OH. Read more Key information about how to submit MDS files and how to obtain and understand error messages on initial and final validation reports.
While most of the information used to establish these codes is already on the Bra assessments, the additional data collection will require both time to complete and training performing correctly. Notably, the addition of completing the admission performance column for section GG (Functional Abilities) will take the most time.
CMS is publishing this final rule consistent with the legal requirements to update Medicare payment policies for SNF son an annual basis. In recognition of the significant impact of the COVID-19 public health emergency, and limited capacity of health care providers to review and provide comment on extensive proposals, CMS has limited annual SNF rule making required by statute to essential policies including Medicare payment to SNES.
In response to stakeholder feedback, we are also finalizing changes to the International Classification of Diseases, Version 10 (ICD-10) code mappings, effective October 1, 2020. Finally, this rule includes minor administrative changes related to the SNF Value-Based Purchasing (VIP) Program.
The ICD-10 MS-DRG Grouper assigns each case into an MS-DRG based on the reported diagnosis and procedure codes and demographic information (age, sex and discharge status). A diagnosis-related group (DRG) is a patient classification system that standardizes prospective payment to hospitals and encourages cost containment initiatives.
In general, a DRG payment covers all charges associated with an inpatient stay from the time of admission to discharge. Dogs categorize patients with respect to diagnosis, treatment and length of hospital stay.
DRG payment is based on the care given to and resources used by a “typical” patient within the group. Many facility contracts include provisions employing a different methodology of calculating payment in outlier situations.
HSA's grouper uses the same DRG case designation categories as Medicare, as defined in the annual Inpatient Prospective Payment System (IPS) Final Rule. Dogs were first implemented nationwide by the Health Care Financing Administration (CFA) to help control costs for inpatient services billed to Medicare.
Providers should refer to the facility contract's Participating Agreement for specific information about HSA's reimbursement methodology and definition for DRG cases. Note: Charges for non-covered services, such as personal care and convenience items, are the member's responsibility.
HSA's DRG Payment schedule for the current year is included in the facility's Participating Agreement. HSA reserves the right to update the DRG payment schedule at other times during the year as necessary.