Home health agencies will face a changed Medicare billing landscape in 2020, and a comprehensive management plan for this transition is critical. Implementation of the CMS’ Patient Driven Groupings Model (PDGM) will not only switch the unit of home health care payment from a 60-day episode of care to a 30-day period, but will also change the case mix adjustment impacting your agency’s level of payment. According to an article in Home Health Care News in 2019, around 40 percent of the primary diagnoses currently allowed will no be accepted under the PDGM.

The following describes the differences between the current Medicare payment system to home health agencies, and how the impending payment overhaul under the PDGM can impact care of your dementia-afflicted clients.

Liberty Consulting and Management Services provides billing and financial services for home health and hospice agencies, so can assist you in preparing for the PDGM.

Understanding the PDGM’s Case Mix Options

There are 153 case-mix groups (Home Health Resource Groups [HHRGs]) under the current Prospective Payment System (PPS). In contrast, the PDGM involves 482 possible case-mix adjustment payment groups. Furthermore, there are five categories encompassing these 482 case-mix adjustment groups as follows: 

  • Admission source (community versus institutional);
  • Timing;
  • Clinical grouping;
  • Functional impairment level;
  • Comorbidity adjustment

The information entered into a client’s Outcome and Assessment Information Set (OASIS) has to clearly correspond to the selected case-mix for that client. Consequently, training your nursing and Medicare billing staff regarding the new (and far more complex) case-mix groups will need to occur in preparation for the commencement of the PDGM.

How a Diagnosis of Dementia Can Affect the Case-Mix Group

The National Stroke Association notes that vascular dementia often results from a stroke. Short-term memory loss and poor concentration occur in at least 45 percent of people living with multiple sclerosis (MS), and MS often leads to the need for diverse home health services. Meanwhile, 10 percent of all adults aged 65 and older have Alzheimer’s disease (per the Alzheimer’s Association).

Since around one-third of all home health clients (and 16 percent of hospice clients) have some form of dementia, your staff needs to understand the proper coding of dementia under the PDGM so that OASIS data and Medicare billing data for each client with be in alignment.

Adults with dementia are more likely to mistakenly ingest an incorrect dose of their medication or forget entirely to take their prescribed medication. Likewise, these adults are also more likely to be unable to correctly follow post-hospitalization instructions after surgery. In turn, skilled nursing and/or therapy home visits can be impacted by this lack of capacity to perform adequate self-care or follow health-related instructions.

Beginning in 2020, OASIS codes will be utilized in order to determine the PDGM categorization of functional level (categorized as low impairment, medium impairment, or high impairment) – and OASIS code changes are also planned for 2020. Therefore, your staff will probably need to undergo OASIS retraining to ensure that their OASIS knowledge base is up-to-date and accurate. In addition, it is advisable to have your staff double-check the OASIS information entered for each client to ensure that the information is complete.

Changes to OASIS

Although a host of changes to OASIS (OASIS-D) occurred on January 1, 2019, changes by the CMS to OASIS (OASIS-D1) will be implemented on January 1, 2020. These changes include the addition of two items to the follow-up assessment instrument. (These are pursuant to CMS Home Health Final Rule 1689-FC, that includes the implementation of the PDGM.)

The two added OASIS items for follow-up assessment are: 

  • M1033 – Risk for hospitalization.
  • M1800 – Grooming.

Clinical Grouping Options and Dementia

There are 12 options within clinical grouping as a case-mix category under the PDGM, and dementia is not one of them. However, the clinical grouping is determined by the principal diagnosis reported on the home health care claim.

Categories of comorbidities are utilized to encompass secondary diagnoses under the PDGM. Two of these listed categories that may apply to a dementia-afflicted client are neurological conditions and behavioral health issues. In contrast to the current PPS, anticipating revenues resulting from Medicare billing under the PDGM needs to incorporate the comorbidity adjustment that is derived from the 24 possible secondary diagnoses.

Why Comorbidity Payment Adjustments are a Factor in Your Medicare Billing

For any client’s secondary diagnosis reported on a claim for services rendered in a 30-day period under the PDGM, the CMS-determined payment adjustment will be one of the following: 

  • No comorbidity adjustment;
  • Low comorbidity adjustment;
  • High comorbidity adjustment

A high comorbidity subgroup classification applying to dementia is possible when the comorbidity subgroup of Neuro 3 is linked to both comorbidity subgroup interaction 25 and comorbidity subgroup of Skin 4. This illustrates the complexity of predicting how a comorbidity classification can impact the per client comorbidity payment adjustment to your agency in order to assess your monthly revenue stream.

The rationale for the comorbidity payment adjustment (as well as the entire PDGM model) is that home health care payments should be determined by patient characteristics and outcomes – rather than therapy volume. Yet – if a claim based on a 30-day period is submitted to Medicare for a client who was only allowed a few home health visits following hospital discharge – a decreased payment adjustment can occur.  

Impact of Low Utilization Payment Adjustments (LUPAs)

According to an article in HomeCare in 2019, Low Utilization Payment Adjustment (LUPAs) will become more challenging for home health agencies under the PDGM. Instead of five or fewer home health care visits as the LUPA threshold, a six-visit threshold combined with a complex structure of variables under the PDGM will be utilized. This article recommends that agencies conduct an intensive review of the LUPAs that have occurred at their agency in the past year.

It is a good idea to maintain internal documentation of LUPAs that includes whether the LUPA was due to the following:  

  • Missed home health visit (g., client missed appointment due to visit to their physician’s office).
  • Staffing issues (g., no registered nursing [RN] staff at home health agency available at pre-scheduled time of visit to client).
  • Patient refusal of care.
  • Scheduling issues (g., client requested a time for nurse or therapist visit that was outside of home health agency’s hours of availability).

Whether you are located in Illinois or elsewhere, contacting Liberty Consulting and Management Services for assistance with Medicare billing and other financial services may enable you to better prepare for the PDGM.writing!