JeoparD PDGM QIRT-FINAL handout · Final Jeopardy OASIS in the Mix - $100 What non -ADL M item(s) has been added to the PDGM functional calculations? uAnswer: M1033 Risk of Hospitalization.
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M1033 Risk for Hospitalization had been added to the calculation of the OASIS functional level.
This item will use clinician judgement to answer the characteristics that may indicate the patient is at risk for hospitalization. Does not include #8, 9, or 10.
uCognitive items were looked at closely for inclusion, however research data indicated that these items demonstrated a decrease in resource use and therefore were not included.
uOther OASIS items considered but left out of model:
4. Signs and symptoms Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many, but not all, codes for symptoms. See Section I.B.18 Use of Signs/Symptom/Unspecified Codes
5. Conditions that are an integral part of a disease process Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
u409.44(c)(1)(a) of the CoPs state “the patient’s clinical record must include documentation describing how the course of therapy treatment for a patient’s illness or injury is in accordance with acceptable professional standards of clinical practice.”
u If there is not an identified cause of muscle weakness then it would be questionable whether the course of therapy treatment would be in accordance with professional standards.
uThe HH PPS Final Rule of 2008: Muscle weakness was also identified as a nonspecific condition that represents general symptomatic complaints in the elderly population.
uIt was further stated that inclusion of such codes into case mix status “would threaten to move the case mix model away from a foundation of reliable and meaningful diagnosis codes that are appropriate for home care”.
M62.81 Muscle weakness (generalized) 3R26.89 Other abnormalities of gait and mobility 24M54.5 Low back pain 33R26.81 Unsteadiness on feet 37R53.1 Weakness 38R26.9 Unspecified abnormalities of gait and mobility 42R29.6 Repeated falls 43R26.2 Difficulty in walking, not elsewhere classified 51M19.90 Unspecified osteoarthritis, unspecified site 57Z48.89 Encounter for other specified surgical aftercare 61M06.9 Rheumatoid arthritis, unspecified 71Z51.89 Encounter for other specified aftercare 76R33.9 Retention of urine, unspecified 82R55 Syncope and collapse 92C34.90 Malignant neoplasm of unsp part of unsp bronchus or lung 93M19.91 Primary osteoarthritis, unspecified site 96Z91.81 History of falling 100R13.10 Dysphagia, unspecified 101M25.561 Pain in right knee 102R42 Dizziness and giddiness 108M54.9 Dorsalgia, unspecified 111M25.551 Pain in right hip 117
Top 20 Non-valid Primary Codes in PDGM (2017 data)
uCoP 484.55(d)(1)(ii) states HHA are required to update the comprehensive assessment.
uCoP 484.18(b) every 60 days (or more frequently) the total plan of care is reviewed by the attending physician and HHA personnel as often as the patient’s condition requires, or when there is a beneficiary elected transfer, or a significant change in condition resulting in a change in the case-mix assignment, or discharge and return to the same
A follow-up assessment would be submitted before the start of the second 30-day period to reflect a major change in condition and then the second 30-day claim would be grouped in appropriate case mix group.
This is different than the current payment model where a case mix group does not change in the middle of a 60-day episode. However, similar to the current system the case mix group cannot be adjusted within the 30-day period.
According to the final rule, this is a way to capture the common types of care provided and more accurately align payments with the costs of providing care or in other words: resource use.
Answer: Created to help further distinguish this clinical grouping and the differences in care to allow for greater transparency in resource use, not because of any increase in resource utilization currently.
• Interventions and treatment aimed at mitigating signs and symptoms of the condition may vary depending on the cause.
• For example: R26.89 “other abnormalities of gait and mobility” would require the clinician to know what is precipitating the abnormality. A plan of care for gait issues related to a neurological diagnosis is different than a gait abnormality related to an injury.
• “By the time a patient is referred to home health and meets the qualifications of eligibility, we would expect that a more definitive code exists to substantiate the need for services.”
• The final rule cited examples of code updates related to the grouper updates.
• Addition of the following codes after comments:• Exact type of fracture (site should be identified)• I13.2 unlikely patient is covered under ESRD benefit for
hypertension• Z46.6 Encounter for fitting and adjustment of urinary
device now grouped under Complex Nursing clinical group
• A41.9 Sepsis approved since the underlying code for the systemic infection should be listed first
uThe BBA congressionally mandated PDGM to be budget neutral or rather it would not result in an overall reduction in Medicare reimbursements for the home health industry.
uHowever, CMS has made certain assumptions about how HHA will respond to the new payment model.
uBased on these assumptions, they have lowered the 30-day payment amount needed to be neutral down, calling it a “behavioral adjustment”.
uFraudulent agencies submit a RAP but never a final bill.
u In the PDGM proposed rule, CMS detailed specific instances of severe abuse.
uOne agency in Michigan submitted a total of over 50 million in RAP payments and received over 37 million in RAP payments but never submitted a claim over 10 months. When CMS went out to the home health agency address, it was vacant.
uThe 10th percentile of each clinical group was decided upon based on the fact that this obtained the 7.1% amount of LUPAs the closest to the current 8% level of LUPAs in the HHPPS payment model.
uWill be re-evaluated each year based on most current data available
uCY2020 will be updated using the HH PPS CY2018 home health data
uRequires the highest utilization to avoid LUPA status
uBy nature, MS rehab represents what CMS considers to be primarily a therapy episode. Therapy episodes often represent the highest utilization of resources.
uThere is no difference in the LUPA threshold related to the presence of comorbid diagnoses solely based on the primary diagnosis.
uConcerns raised during comment period that NRS would not be sufficiently covered. These costs seem to be related to functional levels and patient needs.
uCMS answered that this methodology of including NRS with the per visit adjustment with LUPAs has been rebased and is the highest it can be by law.
uCMS points out that though some LUPA thresholds are affected by the functional scores, that OASIS data is looked at a whole and it is important that agencies have the OASIS accurately reflect the services provided.
What is the highest and lowest paying clinical groupings?
Answer: Behavioral Health clinical grouping late/ community, low functional impairment level is the lowest CMI and Wound clinical grouping early/institutional, high functional impairment level has the highest CMI.
• What goes into the 432 case-mix clinical groupings• How the 60-day OASIS episode breaks down into
two 30-day payment periods• Episode timing and the negative effect late timing
has on case mix• Comorbidities that generate low adjustment• Comorbidities that interact for high adjustment• Behavioral adjustment and budget neutrality• Split payments and RAP payments
u Medicare Learning Network: Overview of the Patient-Driven Groupings Model (PDGM) February 12, 2019, file:///C:/Users/pamel/Documents/PDGM/CMS%20Presentation_2019-02-12-PDGM.pdf
u Medicare Home Health Prospective Payment System: Case-Mix Methodology Refinements, Overview of the Home health Groupings Model, https://downloads.cms.gov/files/hhgm%20technical%20report%20120516%20sxf.pdf
u Centers for Medicare & Medicaid Services Patient-Driven Groupings Model: Overview of the Patient-Driven Groupings Model, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/Overview-of-the-Patient-Driven-Groupings-Model.pdf
u Federal Register/Vol. 83, No. 219/Tuesday, November 13, 2018/Rules and Regulations,
u www.CMS.gov, Home Health Agency (HHA) Center: PDGM Grouper Tool CY 2019 (Updated 11/06/2018), and CY 2019 Case-Mix Adjustment Variables and Scores (Table 3).