Diagnosis Coding: Check Out The Secondary Dx Groups That Will Boost PDGM Pay

CMS listened to HHGM commenters and revised the case mix category methodology.

The newly proposed payment reform model will increase payment for an episode when the claim contains certain secondary diagnoses.

To receive a “low” comorbidity adjustment under PDGM, an episode must have at least one code from the following 11 groups:

Neuro 11 (Includes diabetic retinopathy and other blindness)
Neuro 10 (Includes diabetic neuropathies)
Circulatory 9 (Includes acute and chronic embolisms and thrombosis)
Heart 11 (Includes heart failure)
Cerebral 4 (Includes sequelae of cerebrovascular diseases)
Neuro 5 (Includes Parkinson’s Disease)
Skin 1 (Includes cutaneous abscess, cellulitis, and lymphangitis)
Neuro 7 (Includes hemiplegia, paraplegia, and quadriplegia)
Circulatory 10 (Includes varicose veins with ulceration)
Skin 3 (Includes diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers)
Skin 4 (Includes stages Two-Four and unstageable pressure ulcers by site).

To receive a “high” comorbidity adjustment under PDGM, an episode must have codes from at least one of the following 27 pairs of groups:

  • Circulatory 4 (Hypertensive Chronic Kidney Disease) and Neuro 11 (Includes diabetic retinopathy and other blindness)
  • Endocrine 3 (Diabetes with Complications) and Neuro 7 (Includes hemiplegia, paraplegia, and quadriplegia)
  • Neuro 3 (Dementia in diseases classified elsewhere) and Skin 3 (Diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers)
  • Circulatory 4 (Hypertensive Chronic Kidney Disease) and Skin 1 (Cutaneous abscess, cellulitis, and lymphangitis)
  • Cerebral 4 (Sequelae of Cerebrovascular Diseases Heart) and Heart 11 (Heart Failure)
  • Neuro 7 (Includes hemiplegia, paraplegia, and quadriplegia) and Renal 3 (Nephrogenic Diabetes Insipidus)
  • Circulatory 10 (Includes varicose veins with ulceration) and Endocrine 3 (Diabetes with Complications)
  • Heart 11 (Heart Failure) and Neuro 5 (Parkinson’s Disease)
  • Heart 12 (Other Heart Diseases) and Skin 3 (Diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers)
  • Neuro 3 (Dementia in diseases classified elsewhere) and Skin 4 (Stages Two-Four and unstageable pressure ulcers by site)
  • Behavioral 2 (Mood Disorders) and Skin 3 (Diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers)
  • Circulatory 10 (Includes varicose veins with ulceration) and Heart 11 (Heart Failure)
  • Circulatory 4 (Hypertensive Chronic Kidney Disease) and Skin 3 (Diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers)
  • Renal 1 (Chronic kidney disease and ESRD) and Skin 3 (Diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers)
  • Respiratory 5 (COPD and Asthma) and Skin 3 (Diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers)
  • Skin 1 (Cutaneous abscess, cellulitis, and lymphangitis) and Skin 3 (Diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers)
  • Renal 3 (Nephrogenic Diabetes Insipidus) and Skin 4 (Stages Two-Four and unstageable pressure ulcers by site)
  • Heart 11 (Heart Failure) and Skin 3 (Diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers)
  • Heart 12 (Other Heart Diseases) and Skin 4 (Stages Two-Four and unstageable pressure ulcers by site)
  • Respiratory 5 (COPD and Asthma) and Skin 4 (Stages Two-Four and unstageable pressure ulcers by site)
  • Circulatory 7 (Atherosclerosis) and Skin 3 (Diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers)
  • Renal 1 (Chronic kidney disease and ESRD) and Skin 4 (Stages Two-Four and unstageable pressure ulcers by site)
  • Endocrine 3 (Diabetes with Complications) and Skin 4 (Stages Two-Four and unstageable pressure ulcers by site)
  • Endocrine 3 (Diabetes with Complications) and Skin 3 (Diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers)
  • Circulatory 4 (Hypertensive Chronic Kidney Disease) and Skin 4 (Stages Two-Four and unstageable pressure ulcers by site)
  • Heart 11 (Heart Failure Skin) and Skin 4 (Stages Two-Four and unstageable pressure ulcers by site)
  • Skin 3 (Diseases of arteries, arterioles and capillaries with ulceration and nonpressure chronic ulcers) and Skin 4) Stages Two-Four and unstageable pressure ulcers by site).

Source: Tables 44 and 45, 2019 Home Health Prospective Payment System proposed rule.

Source- SuperCoder

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