Transitioning to the Patient-Driven Groupings Model (PDGM) has already begun to impact operations for home health agencies that are indeed convinced that preparation must begin now.  Diagnosis coding and OASIS ADL data are two significant areas that the agency can impact by deeper education and understanding of both items.  Clinicians must understand the dire importance of including the appropriate disease processes in the assessment of the patient and development of care plans.  In addition, a true functional assessment of the patient and the full understanding of the OASIS response options in the ADLs will be the greatest positive impact in case mix weight calculation and establishing reimbursement.  These factors are huge in PDGM, not only in the calculation of case mix weight and reimbursement, but helping to support medical necessity of the care to be provided to the patient in the medical record.


Clinical Groupings

There are four steps in the grouping of a patient into the PDGM Home Health Resource Group (HHRG), which establishes the case mix weight and eventual payment.  ICD-10 coding makes up 50% of that process.  The primary diagnoses (from the claim) of the patient will be the sole determinant of the Clinical Grouping of the patient.  There are 12 Clinical Groupings:  Medication Management Teaching & Assessment (MMTA) – Other, MMTA: Endocrine, MMTA: Cardiac, MMTA: Surgical Aftercare, MMTA: Infectious, MMTA: GI/GU, MMTA: Respiratory, Wounds, Musculoskeletal Rehab, Neuro Rehab, Complex Nursing Interventions & Behavioral Health.  There is a list of 43,000+ diagnoses that will be allowed as the primary diagnosis of the patient under PDGM.  Without a diagnosis from that list, as the primary diagnosis on the claim, the claim will not be paid.  Home Health software systems will likely allow only valid diagnoses to be utilized, which would allow agencies to know that they are using an allowed code.  Wounds are the highest case mix category and MMTA: Surgical Aftercare is the lowest, with the spread between highest and lowest being 32%.  The primary reason that a code would not group under PDGM is the lack of specificity.  This does not always reference the location on the body – for example:  Pain in left knee….we know where the pain is, but what is causing the pain?


Comorbidity Adjustments

The comorbidity adjustment will be based on the secondary or other diagnoses that are found on the claim.  Up to 25 diagnoses will fit in the electronic claims file.  The comorbidity adjustment has three levels:

  1. No Comorbidity Adjustment – no secondary codes meet criteria
  2. Low Comorbidity Adjustment – only one secondary meets criteria
  3. High Comorbidity Adjustment – two or more secondary meet the criteria

The case mix weight is increased by 6.01% with a Low Comorbidity adjustment and an additional 12.95% if a High Comorbidity adjustment applies.  It is imperative that agencies not only ensure that all diagnoses are coded for the patient, but that they are all reported in the electronic claims file.

The industry is currently waiting for the Final Rule in late October/early November to obtain clarification from CMS on a significant concern.  The concern is 3-fold.  Agencies have 3 different levels of instruction as to what to include as diagnoses:

  • ICD10 Guidelines “All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.”
  • OASIS Manual “Secondary diagnoses are comorbid conditions that exist at the time of the assessment, that are actively addressed in the patient’s Plan of Care, or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis.”
  • CoPs The regulation at §484.60(a)(2) requires that all pertinent diagnoses be included in the POC. CMS, in their guidance document for this regulation, defines pertinent diagnoses to “mean all known diagnoses.” This is a very different instruction than listing diagnoses that have either an actual impact or potential impact on the treatment plan. The varying instructions make it possible for the POC to have more diagnoses than the OASIS and the OASIS and the POC to have more diagnoses than the claim.

The list of all diagnoses that the patient may use as primary and the list of secondary codes that are used for the comorbidity adjustment are found at the following link:

The primary thing agencies need to take away from this is that there will need to be much documentation gathered at intake/admission of the patient in order to have everything needed to appropriately code the patient’s diagnoses.  Lack of specificity begins with the physician and must be dealt with.  Agencies will need to begin, as soon as possible, going back to the physician for more specific information when lacking.

Healthcare Provider Solutions understands that thorough preparation is the key to success under PDGM.

We are dedicated to supporting HHAs with a customized PDGM Impact Analysis, outsourced billing solutions, and continued PDGM education. Our team of seasoned industry professionals is currently guiding agencies nationwide to a smooth PDGM transition.

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