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Home Health PPS: Home Health Patient-Driven Groupings Model

Guidance for a new case-mix classification model which relies more heavily on clinical characteristics, and other patient information to place home health periods of care into meaningful payment categories.

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: August 03, 2020

Medicare Home Health Prospective Payment System (HH PPS) Calendar Year (CY) 2023 Behavior Change Recap, 60-Day Episode Construction Overview, and Payment Rate Development Webinar

On March 29, 2023, CMS provided an overview of several provisions from the CY 2023 HH PPS final rule on behavior changes, the construction of 60-day episodes, and payment rate development.

Topics:

  • Description of actual behavior changes that occurred between CY 2018 and CY 2021
  • Approach used to construct simulated 60-day episodes using 30-day periods
  • Overview of payment rate development for CY 2023
  • Information on new data files containing information on the simulated 60-day episodes and actual 30-day periods used in calculating the permanent adjustment to the payment rate

Event Materials

  • Presentation (PDF) which includes a description of the actual behavior changes that occurred between CY 2018 and CY 2021
    • An updated presentation was posted on 04/14/2023 to correct two errors on slides 35 and 42. 
  • CY 2023 Descriptive Statistics from Supplemental LDS Files (ZIP) spreadsheet which contains information on the number of simulated 60-day episodes and actual 30-day periods in CY 2021 that were used to construct the permanent adjustment to the payment rate. The spreadsheet provides information such as the number of episodes and periods by case-mix group, case-mix weights, and simulated payments.
  • Supplemental Limited Data Set (LDS) files for CY 2023 rulemaking that include the simulated 60-day episodes and actual 30-day periods used to calculate the permanent adjustment to the payment rate. The LDS files can only be obtained through purchase and also submission of a Data Use Agreement (DUA).

For More Information:

 

Implementation of New International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Diagnosis Codes, Effective April 1, 2020:

The Center for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) has implemented two new ICD-10-CM diagnosis codes, effective April 1, 2020:

  1. In response to the national emergency that was declared concerning the COVID-19 outbreak, NCHS is implementing a new diagnosis code, U07.1, COVID-19, into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and;
  2. In response to recent occurrences of vaping related disorders, the NCHS is implementing a new diagnosis code, U07.0, Vaping-related disorder, into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), for reporting vaping-related disorders.

Both U07.1, COVID-19 and U07.0, Vaping-related disorder are assigned to the Medication Management, Teaching and Assessment-Respiratory (MMTA-Respiratory) clinical group for purposes of case-mix adjustment under the HH PPS. Additionally, U07.1, COVID-19, is added to a new comorbidity subgroup, Respiratory 10, and will receive the Low Comorbidity adjustment under the HH PPS case-mix system effective for home health claims with From Dates on or after April 1, 2020 and included in the Home Health Patient-Driven Groupings Model (HH PDGM) Grouper software package, v01.1.20, available for download on the HH Grouper Software webpage.

Overview of the HH PPS Case-Mix Model:

CMS finalized a new case-mix classification model, the Patient-Driven Groupings Model (PDGM), effective January 1, 2020. The PDGM relies more heavily on clinical characteristics, and other patient information to place home health periods of care into meaningful payment categories.  One case-mix variable is the assignment of the principal diagnosis to one of 12 clinical groups to explain the primary reason for home health services.

30-day periods are categorized into 432 case-mix groups for the purposes of adjusting payment under the PDGM. In particular, 30-day periods are placed into different subgroups for each of the following broad categories:

  • Admission source (two subgroups): community or institutional admission source
  • Timing of the 30-day period (two subgroups): early or late
  • Clinical grouping (twelve subgroups): musculoskeletal rehabilitation; neuro/stroke rehabilitation; wounds; Medication Management, Teaching, and Assessment (MMTA)
    • surgical aftercare; MMTA - cardiac and circulatory; MMTA - endocrine; MMTA -gastrointestinal tract and genitourinary system; MMTA - infectious disease, neoplasms, and blood-forming diseases; MMTA - respiratory; MMTA- other; behavioral health; or complex nursing interventions
  • Functional impairment level (three subgroups): low, medium, or high
  • Comorbidity adjustment (three subgroups): none, low, or high based on secondary diagnoses.

In total, there are 2*2*12*3*3 = 432 possible case-mix adjusted payment groups.

Resources:

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.