CMS originally specified six groupings. The number was doubled in the final rule, expanding the classifications from six to 12 with the addition of seven Medication Management, Teaching and Assessment MMTA subgroups. The PDGM will classify each day period of care by principal diagnosis into one of 12 clinical groups or subgroups:.
CMS designed the clinical groups to capture the most common types of care provided and originally specified six clinical groups. The number was doubled in the final rule, expanding the classifications from six to 12 with the addition of seven MMTA sub-groups.
What it means for HHAs : It is important to remember that the principal diagnosis determines which clinical group a patient will be assigned to, and CMS makes the assumption that HHAs will modify their coding practices under PDGM to ensure that the highest paying diagnosis code is listed as the principal diagnosis. It is imperative that agencies do this in order to optimize reimbursement under PDGM.
Points reflect relative resource use; OASIS item responses that indicate higher functional impairment and a higher risk of hospitalization are assigned higher points.
CMS then uses a regression model to assign Functional Impairment points thresholds for low, medium, and high impairment levels to each PDGM clinical grouping. This score is then compared with the PDGM clinical grouping thresholds to determine whether the day period is assigned a low, medium, or high functional impairment level. What it means for HHAs : day periods in the low level of functional impairment generally have OASIS item responses that are associated with the lowest resource use.
According to CMS, comorbidity is tied to poorer health outcomes, more complex medical needs and management, and higher care costs. What it means for HHAs : It is important to note that the comorbidity adjustment for a day period will be classified as high if the interaction of two or more secondary diagnoses results in higher resource use.
This is the case even if any or all of the diagnoses are not individually associated with higher resource use. Thorough assessments, ongoing reassessments and accurate documentation are critical to this assumption.
Currently, LUPA occurs when there are four or fewer visits during a day episode of care. What it means for HHAs : This is a big change. This means that clinicians and billers will need to know the LUPA threshold for each patient.
Industry experts believe the implied endorsement of this technology will spur further technological developments in the home healthcare arena. Case-mix weights are determined by dividing the predicted resource use for each HHRG by the overall average resource use of all day periods and are then used to adjust the day payment rate. Outlier Payments : Outlier payments currently are made for day episodes of care with estimated costs that exceed a designated threshold amount.
Under PDGM, periods with estimated costs of care that exceed a specific outlier threshold will receive an outlier payment for that day period. Outlier Payment calculations will remain the same as they are currently. Home Infusion Therapy : According to CMS, the final rule implements the temporary transitional payments for home infusion therapy services, as required by the Bipartisan Budget Act of What are the three categories of CPT codes?
CPT codes are used for reporting devices and drugs including vaccines required for the performance of a service or procedure, services or procedures performed. Where can I find a list of CPT codes? Radiology Procedures. Pathology and Laboratory Procedures. Medicine Services and Procedures.
Evaluation and Management Services. Category II Codes. Multianalyte Assay. What is a service code? A service code is a special code that applies a discount to the TurboTax Online fee provided by our support specialists for specific, pre-determined reasons. They aren't considered online coupons or "groupons". Service codes are valid through October 15 and can be used only once. What is a CMS tool?
Stands for "Content Management System. In the example listed above, 4CC11 has a case-mix of 1. It is essential for providers to ensure they are receiving every penny they deserve based on the appropriate care provided to the patient. In addition, agencies must have the capability to analyze and manage their case-mix. A drop in the case-mix could result in the loss of hundreds to thousands of dollars for an agency. Axxess has built features into our software that empower providers with data to manage case-mix and calculate the revenue impact of PDGM.
These features enable education, visibility, and training for leaders and other staff to make changes now so they will be ready for PDGM. In addition to resources available online , Axxess is leading the way to train the industry on exactly what agencies should do to thrive when the new payment model takes effect. Registration at one of our interactive one-day seminars is open.
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