Table of Content
- Careers
- License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition
- Partial Payment Adjustment
- How A Valuation Gap Between Buyers, Sellers In Home-Based Care Is Affecting M&A
- Ways to Transform Triage Through Actionable Data, Intelligent Resourcing, and Faster Response Times
- Home Health PPS
- How will PDGM impact MSP?
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. Each of the 432 case-mix group has a threshold to determine if the period of care would receive a LUPA.
CMS states that these are too vague and they don’t provide enough information to support the need for home health services. Claims that have unacceptable primary diagnoses will be “returned to provider” because CMS cannot assign the 30-day period to a clinical group for payment. Cutting payment periods in half, from 60-day episodes to 30-day periods of care.
Careers
As case mixes change, agencies will need to take measures to ensure that their staff’s competency meets the level of acuity. For many, this paradigm shift is stimulating major internal changes to both optimize reimbursement and ensure quality care. 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’ assessment.
PDGM replaces the previous reimbursement model called Prospective Payment System which was implemented in 2000. ICD-10 Diagnosis Coding, OASIS Data, and Therapy Utilization. Centers for Medicare and Medicare Services used PPS for 20 years with updates along the way. Over time, CMS continued to issue guidance on important items in reimbursement- particularly diagnosis coding and therapy utilization. CMS wanted all along to have diagnosis coding be at the highest level of specificity and to use therapy for what the patient needed. Therapy over utilization and coding became problematic and PDGM was proposed several times over the years but finally was implemented January 1, 2020.
License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition
PDGM can be complicated, but if nurses and agencies understand the need for documentation, then the picture is much easier to paint for optimal reimbursement. And ensure that the OASIS and other assessment items are consistent and coordinated are successful. Those that do all of this in a timely manner are even more successful. There were a lot of home health agencies that were well prepared for PDGM.
No acute or post-acute care in the 14 days prior to the HH admission. Late episode of care – Third episode and beyond in a sequence of adjacent covered episodes. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA.
Partial Payment Adjustment
Like many new rules and policies, it is expected that additional legislation will be introduced after PDGM takes hold, which will improve and update the system. The NAHC has already begun efforts to advocate for legislation that would stop Congress from enacting any new changes based solely on predictions of agency and patient behavior as opposed to actual events. A number of bills which involve areas of PDGM have already been floating around the Senate and the House of Representatives from members of both major political parties.
Seamlessly supplement your clinical assessments with CareScout’s nationwide network of 35,000+ registered nurses. One of the biggest areas of PDGM that has been in the spotlight is in regard to therapy. That balancing act is even more important with PDGM, which must be budget neutral, as mandated by Congress.
Within the current system, home health providers receive a LUPA claim for providing 4 or less visits over 60-day care episodes within any category of patient delivered care. Providers then in turn only get a standardized per-visit payment, no matter the cause for fewer recorded visits. The new PDGM rules will effectively transform that universal four-or-fewer rule and morphs it into 216 differing scenarios. In consequence, estimated LUPA rates are expected to fall from 8% to 7.1% once PDGM takes effect, with scattered predictions that they may increase.
Therefore, with PDGM therapy was removed as a component of the reimbursement calculation. Home Health Agencies now use a combination of diagnosis coding and OASIS data to determine the reimbursement rate. Other components used in the calculation is episode timing (early/late), referral source (institutional/community)- which institutional results in an automatic 10% increase in reimbursement. With all of this data together, a reimbursement amount is determined- independent of the amount of visits/therapy needed.
Providers who have successfully navigated PDGM and are seeing positive returns from the updated payment model will actively seek agencies who were not as prepared for PDGM and are suffering from its effects. This event explores the strategies for deals, investments and transactions in the home health, home care, hospice and palliative care space. Yet because of the COVID-19 pandemic, any major recalibrations or corrections to PDGM’s foundation have, so far, been delayed, according to National Association for Home Care & Hospice President William A. Dombi. That could begin to change later in 2022, when CMS is gearing up to release its proposed payment rule for 2023.
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. Home Care Answers helps many agencies across the country with varying census from 15 patients to over 500. We provide a complimentary chart audit to create enough data to give some guidance. Almost without fail, one of our first suggestions is improving documentation. While it’s likely true that PDGM did have some influence on therapy utilization, finding out how much is nearly unquantifiable.
We also help make sure that accurate data is sent to CMS to ensure that potential adjustments and tweaks are based on good data. 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. Nurses absolutely can document and send to physician to verify what the nurse documents or if something isn't found in an History and Physical summary. If a diagnosis isn't relevant to a physician, they may not document it, but it could certainly impact the care and outcome of a patient.
PDGM presents one widely recognized challenge for home health agencies involving diagnoses. Estimates suggest that nearly 50% of the diagnoses permitted under the PPS will likely be rejected as ineligible to be classified as primary. With the new policies PDGM presents, case mix will be partially determined by a patient’s functional inabilities. Subsequently this presents a scenario where over 430 combinations can occur under PDGM, while PPS presents only 153.
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