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New PDGM is HHGM with a few tweaks.<\/em><\/strong><\/span><\/p>\n If you didn\u2019t like Medicare\u2019s ideas on home health payment reform last year, you\u2019re probably not going to be happy with its newly proposed model either.<\/p>\n Why?<\/span>\u00a0<\/strong>The Patient-Driven Groupings Model unveiled in the 2019 Home Health Prospective Payment System proposed rule is largely the same as the Home Health Groupings Model that the\u00a0Centers for Medicare & Medicaid Services\u00a0<\/strong>proposed \u2014 and then withdrew \u2014 in 2018\u2019s rule.<\/p>\n One big difference, however, is the price tag. As required in the Bipartisan Budget Act of 2018 enacted earlier this year, CMS has proposed the new PDGM payment reform model as budget neutral. That\u2019s in sharp contrast to the agency\u2019s plan for HHGM to strip nearly $1 billion from home health spending in its first year alone.<\/p>\n \u201cBudget neutrality is certainly a good thing,\u201d even if it \u201cwas expected based on the Bipartisan Budget Act of 2018,\u201d notes reimbursement expert\u00a0M. Aaron Little\u00a0<\/strong>with\u00a0BKD\u00a0<\/strong>in Springfield, Missouri.<\/p>\n \u201cBudget neutral is a major improvement \u2014 if it holds up,\u201d cautions consultant\u00a0Joe Osentoski\u00a0<\/strong>with\u00a0Quality in Real Time\u00a0<\/strong>in Troy, Michigan.<\/p>\n While budget neutrality is a major difference, it\u2019s about the only one. As with HHGM, under PDGM agencies would see reimbursement for their episodes determined by four steps once the model takes effect in January 2020:<\/p>\n Step 1:<\/span>\u00a0<\/strong>Classify episodes into four categories based on timing and source of admission \u2014 Community Early, Community Late, Institutional Early, Institutional Late. Under PDGM, higher reimbursement would go to \u201cinstitutional\u201d episodes (those with hospital, skilled nursing facility, and inpatient rehab facility stays within 14 days of home health admission) and those that are \u201cearly\u201d \u2014 the first or only in a series of nonadjacent episodes.<\/p>\n Don\u2019t forget:<\/span>\u00a0<\/strong>The \u201cearly\u201d versus \u201clate\u201d designation is set by another huge payment change \u2014 a switch to a 30-day billing period, as opposed to PPS\u2019s current 60-day episode. HHAs railed against shortening the billing period length last year, but the BBA 18 law required the change.<\/p>\n Based on industry comments, CMS did explore the idea of considering emergency department and\/or observation stays for the source of admission, it says in the rule scheduled for publication in the July 12\u00a0Federal Register<\/em>. \u201cHome health stays with preceding observational stays and ED visits show resource use that falls between that of the institutional and community categories,\u201d CMS allows.<\/p>\n \u201cHowever, the resource use is not equivalent to that of the institutional settings; therefore, we do not believe it appropriate to include observational stays and ED visits in the institutional category for the purposes of the PDGM,\u201d CMS explains.<\/p>\n CMS also looked into developing a third admission source category just for observational stays and ED visits. \u201cEarly\u201d periods see a 6 percent increase in resource use and \u201clate\u201d periods see a 10 percent increase, according to the rule. That compares to 19 percent and 43 percent for institutional stays.<\/p>\n But \u201cwe are concerned that a third admission source category for observational stays and ED visits could create an incentive for providers to encourage outpatient encounters \u2026 thereby potentially inappropriately increasing costs to the Medicare program overall,\u201d CMS says in the rule.<\/p>\n Numerous commenters on HHGM urged CMS to make the first two 30-day episodes \u201cearly.\u201d CMS again shoots down that request, noting that \u201cHHAs provide more resources in the first 30-day period of home health (\u2018early\u2019) than in later periods of care.\u201d<\/p>\n The early\/late categorization \u201cserves to better align payments with already existing resource use patterns. This alignment of payment with resource use is not to be interpreted as placing a value judgment on particular care patterns or patient populations,\u201d CMS maintains in the rule. \u201cOur goal in developing the PDGM is to provide an appropriate payment based on the identified resource use of different patient groups, not to encourage, discourage, value, or devalue one type of skilled care over another.\u201d<\/p>\n Step 2:<\/span>\u00a0<\/strong>Slot episodes into six clinical groupings based on principal diagnoses reported on the claim: Musculoskeletal Rehabilitation, Neuro\/Stroke Rehabilitation, Wounds \u2014 Post-Op Wound Aftercare and Skin\/Non-Surgical Wound Care, Behavioral Health Care (including Substance Use Disorder), Complex Nursing Interventions, Medication Management, Teaching and Assessment (MMTA). They are the same categories proposed under HHGM.<\/p>\n In last year\u2019s rulemaking, many HHAs gave CMS an earful about the inadequacy of the groupings, particularly the MMTA category. CMS mostly dismisses the complaints, although it notes \u201cwe did \u2026 review and re-group certain codes based on commenter feedback.\u201d<\/p>\n For example:<\/span>\u00a0<\/strong>\u201cWith regard to the classification of N39.0, Urinary tract infection, site not specified as an invalid code to group the home health period of care, we do agree that absent definitive information provided by the referring physician, a home health clinician would not know the exact site of a urinary tract infection (UTI),\u201d CMS says. Therefore CMS will group N39.0 \u201cunder MMTA, as the home health services required would most likely involve teaching about the treatment for the UTI, as well as evaluating the effectiveness of the medication regimen\u201d under PDGM.<\/p>\n CMS explored using MMTA subgroups, but found that \u201coverall, using the MMTA subgroup model would result in more payment groups but not dramatic differences in case-mix weights across those groups,\u201d according to the rule.<\/p>\n Step 3:<\/span>\u00a0<\/strong>Assign episodes as Low, Medium or High functional levels based on OASIS responses (see OASIS items, p. 188<\/em>).<\/p>\n CMS rebuffs suggestions to add more OASIS items to the functional methodology.<\/p>\n The rule also notes that \u201cthe functional level adjustment is not meant to be a direct proxy for the therapy thresholds\u201d that PDGM eliminates.<\/p>\n Step 4:<\/span>\u00a0<\/strong>Adjust for comorbidities based on secondary diagnoses. This last step is one place that CMS does make a significant change, compared with HHGM \u2014 but it may not be exactly what industry members were hoping for.<\/p>\n The difference:<\/span>\u00a0<\/strong>Instead of getting one adjustment level for any and all qualifying comorbidity diagnoses, PDGM would give episodes a \u201cno,\u201d \u201clow,\u201d or \u201chigh\u201d comorbidity adjustment. An episode would receive no adjustment if it had no qualifying diagnoses, a \u201clow\u201d adjustment for one qualifying diagnoses from a group of 11 categories, and a \u201chigh\u201d adjustment for two or more qualifying diagnoses from a group of 27 categories. (See qualifying diagnoses groups, this page.<\/em>) Episodes would receive either \u201clow\u201d or \u201chigh\u201d adjustments, not both.<\/p>\n In other words, \u201cthe low comorbidity adjustment amount would be the same across all 11 individual comorbidity subgroups,\u201d CMS explains. \u201cSimilarly, the high comorbidity adjustment amount would be the same across all 27 comorbidity subgroup interactions.\u201d<\/p>\n CMS made the change because \u201ccompelling evidence that patients with certain comorbidities and interactions of certain comorbid conditions \u2026 have home health episodes with higher resource use than home health episodes without those comorbidities or interactions,\u201d it acknowledges.<\/p>\n The result:<\/span>\u00a0<\/strong>PDGM\u2019s four steps result in one of 216 Home Health Resource Groups. That\u2019s up from 144 case mix groups under HHGM, due to the comorbidity methodology change. (Reminder: The original HHGM proposal contained 128 groups.)<\/p>\n What\u2019s Missing?<\/strong><\/span><\/p>\n As with HHGM, PDGM does not include therapy utilization at all in its case mix calculation methodology.<\/p>\n Based on urging from the\u00a0Medicare Payment Advisory Commission<\/strong>,\u00a0HHS Office of Inspector General<\/strong>, and others, CMS has expressed an interest in cutting therapy utilization from its HH PPS case mix system for quite some time. But when it proposed the change last year, the agency received a lot of pushback from industry members.<\/p>\n Thanks to BBA 18, that issue is now out of CMS\u2019s hands. \u201cWe have no regulatory discretion in this matter,\u201d CMS says, referring to the law that \u201cprohibit[s] the use of therapy thresholds as part of the overall case-mix adjustment for CY 2020 and subsequent years.\u201d<\/p>\n But CMS does note that PDGM \u201chas other case-mix variables to adjust payment for those patients requiring multiple therapy disciplines,\u201d the rule indicates when discussing the model\u2019s functional determination case mix step. \u201cWe believe that also accounting for timing, source of admission, clinical group (meaning the primary reason the patient requires home health services), and the presence of comorbidities will provide the necessary adjustments to payment to ensure that care needs are met based on actual patient characteristics.\u201d<\/p>\n Industry observers, however, are less sanguine about the prospect of PDGM making up for the therapy utilization factor elimination.<\/p>\n Be prepared:<\/span>\u00a0<\/strong>\u201cElimination of therapy thresholds will have a significant impact on service delivery: both type and amount,\u201d Osentoski predicts.<\/p>\n Also:<\/span>\u00a0<\/strong>Separate Nonroutine Supplies (NRS) rates are also missing from the PDGM methodology. Those rates would be rolled into the case mix group amounts, CMS proposes.<\/p>\n Note: See the 600-page 2019 HH PPS proposed rule at\u00a0https:\/\/s3.amazonaws.com\/publicinspection.federalregister.gov\/2018-14443.pdf<\/a>.<\/em><\/p>\n Source- SuperCoder<\/span><\/i><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"