Last Updated on
The Patient-Driven Groupings Model (PDGM) will become a reality in a few short weeks. Home health agencies are indeed preparing and seem to understand the immense situation. The third step in establishing a Home Health Resource Group (HHRG) and corresponding case-mix weight is the Functional Impairment of the patient based on the OASIS-D1 responses. This is a significant part of the PDGM case-mix calculation and one that requires significant education and review of the OASIS-D1 documentation.
The patient’s functional impairment level is based on responses to 8 OASIS-D1 items for activities of daily living (ADL). The 8 OASIS-D1 items include: M1800 – 1840, M1850, M1860 & M1033.
Once the points are calculated from the above table, the total points are taken to the next step of determining the level of impairment dependent on the Clinical Category. This is the ONLY area of the PDGM case-mix calculation that will be taken from the OASIS documentation.
One of the key components to ensuring that this calculation is as accurate as possible is ensuring that OASIS education happens. It is imperative that agencies see the significance of interdisciplinary collaboration with any staff that have seen the patient and that review occurs following completion. This OASIS ADL section not only impacts the PDGM scoring, but it also impacts outcomes, including Value Based Purchasing.
It’s important to note, that under PDGM, agencies will not receive additional or increased reimbursement based on the number of therapy visits provided to the patient. Therefore, it is even more imperative that the OASIS-D1 documentation be as accurate as possible to not only support the case-mix weight for reimbursement, but for medical necessity documentation support.
2019-2020 Transition Follow-Up/Recertification Assessments
The episodes that are going to be Recertification Episodes with a begin date of January 1, 2020 and later will be episodes under PDGM. When a patient is being recertified there is a requirement that the Follow-Up OASIS be completed in the 5 days prior to the begin date of the recertification episode. There are very specific updated instructions for completing and transmitting Follow-Up/Recertification OASIS when this is the case.
When the Follow-Up OASIS is completed within the last 5 days of 2019, CMS will temporarily waive the requirement that HHAs enter the actual “Date the Assessment Is Completed” date in M0090. Instead, agencies are required to enter the M0090 date as 1/1/2020. The agency must wait to transmit the OASIS until 1/1/2020, or there will be a fatal error. With a completion date of 1/1/20 it will cause the OASIS to be the OASIS-D1 version and will appropriately create an OASIS-D1 generated PDGM HIPPS code. The OASIS-D version does not have M1800 or M1033 as a valid part of the Follow-Up dataset so there must be OASIS-D1 utilized in order for the appropriate HIPPS code to create.
Transition Recertification Example:
- Start of Care date: November 3, 2019
- Recertification assessment (using OASIS-D1 Follow-Up (RF4)) is completed on December 29, 2019 (the recertification episode is to begin January 2, 2020)
- Report artificial M0090 date of 1/1/2020
- Submit the OASIS to the ASAP database 1/1/2020 or later
Staying on top of the OASIS changes and compliance can be a challenge while managing patient care and daily priorities. The HPS Alliance is an exclusive resource that regularly provides participating agencies with essential tools to maintain successful operations.
It’s crucial for agencies to get ahead of the curve for success under PDGM. Don’t get left behind!
Healthcare Provider Solutions is dedicated to supporting HHAs with a customized PDGM Impact Analysis, outsourced billing solutions, and continued PDGM education. Our seasoned industry professionals are currently guiding agencies nationwide to a smooth PDGM transition.
2020 is NOT just about PDGM. Sign up for the 2019 year-end update that offers all the last-minute alerts required to be successful in 2020 beyond PDGM. This update will include the required update to iQIES, the mandated full implementation of the Medicare Beneficiary Identifier, the blocked access to the Common Working File, update to the HHCAHPS Survey, the OASIS-D1 implementation requirements, plus last-minute PDGM updates and clarifications.
Join us for this FREE webinar hosted by HPS CEO, Melinda A. Gaboury, to ensure you truly are ready to face 2020 head-on!