Common misconceptions regarding the calculation of the Patient Driven Groupings Model (PDGM) HIPPS codes exist and need clarification.
In the skilled nursing facility industry, there is a three-day hospitalization rule that states that if a patient has spent at least three full days in a hospital, they qualify for skilled nursing facility stays. However, this rule doesn’t apply to home health.
In the PDGM model, institutional credit is given to a patient’s 30-day payment when the patient has been officially admitted to a hospital, skilled nursing facility, LTCH, rehab, or psych facility, and is discharged with a discharge date within 14 days prior to the start of the upcoming 30-day payment period in home health. It’s crucial to confirm that the patient’s stay was an official admission to the facility, and you must have documentation for the discharge date.
On your 30-day final claims, you can use a code, either 61 or 62, based on the type of facility the patient was discharged from. Code 61 is for discharge from an acute care hospital, while code 62 is for discharge from a SNF, LTCH, rehab, or psych facility. By including these codes on your home health claim, you can receive institutional credit for that 30-day payment period, even if CMS or the Medicare MAC does not have a corresponding facility claim in the system. If a 61 or 62 is not included on the claim and there is no facility claim in the system, institutional credit will not be granted. Supposedly, a reconciliation process exists where if an institutional claim is found, the Home Health Agency will receive credit, though this should not be relied on.
Additionally, having the 61 or 62 code on the claim and automatically receiving institutional credit requires supporting documentation within your chart. This documentation is needed for medical review purposes to confirm the official admission to the facility and provide evidence of the discharge date.
When constructing your 30-day payment periods, if a patient who has already been on home health services is transferred to a facility and is officially admitted there, a transfer takes place. Upon returning home from that facility, if the discharge date from the facility falls within 14 days prior to the start of the upcoming 30-day payment period, you should receive institutional credit for that forthcoming 30-day claim.
It’s important to remember that if the patient doesn’t return home until the next 30-day payment period, their payment period will not receive institutional credit. For instance, if the patient returns home on day 35, which falls within the second 30-day period, the patient will have to be discharged and readmitted to home health in order to qualify for institutional credit in the HIPPS code calculation.
Additionally, it’s crucial to keep in mind that for skilled nursing facilities, LTCH, rehab, or psychiatric facility admissions, when a patient has previously received home health services, you must discharge and readmit the patient to qualify for any form of institutional credit, irrespective of the discharge date. Institutional credit for a patient is only given when they have been discharged from a SNF, LTCH, rehab, or psychiatric facility and it marks a brand new start of care for home health.
Should you require assistance with your PDGM HIPPS code calculation, analysis, or review, please feel free to reach out to us.
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