Home Health FAQs - Home Health Patient-Driven Groupings Model (PDGM)

1. It seems as though the (Request for Anticipated Payment (RAP) (TOB 0322) will not go through the grouper tool. Will you use the submitted HIPPS on the RAP to determine the payment amount for the RAP?

According to Section 40.1 (RAP) of the manual revision included in Change Request 11081 (PDF, 819 KB), for RAPs with 'From' dates on or after January 1, 2020, the HHA may submit the HIPPS code they expect will be used for payment if they choose to run grouping software at their site for internal accounting purposes. If not, they may submit any valid HIPPS code in order to meet this requirement. In all cases, grouping of the claim to determine the HIPPS code used for payment will occur in Medicare systems and the submitted HIPPS code will be replaced with the system-calculated code.

2. Will CMS/MACs process Occurrence Codes 61 and 62 on the RAPs when determining payments or just the final claims?

According to Section 40.2 (HH PPS Claims) of the manual revision included in Change Request 11081 (PDF, 819 KB), occurrence code 61 (hospital discharge date) or 62 (other institutional discharge date) are only submitted on final claims, not RAPs.

3. Should occurrence code 50 be submitted on the RAP, or just the final claim?

According to Section 40.2 (HH PPS Claims) of the manual revision included in Change Request 11081 (PDF, 819 KB), occurrence code 50 is submitted on final claims and adjustments with 'From' dates on or after January 1, 2020. The HHA enters occurrence code 50 and the date the OASIS assessment corresponding to the period of care was completed (OASIS item M0090). If occurrence code 50 is not reported on a claim or adjustment, the claim will be returned to the provider for correction.

4. To bill the RAP in the second 30-day period, does the first billable visit within that 30-day period need to be completed, or just scheduled?

The Section 40.1 (Request for Anticipated Payment (RAP)) of the manual revision included in Change Request 11081 (PDF, 819 KB), did not change. For initial episodes, the HHA reports on the 0023 revenue code line the date of the first covered visits provided during the episode. For subsequent episodes, the HHA reports on the 0023 revenue code the date of the first visit provided during the episode, regardless of whether the visit was covered or non-covered.

In addition, according to Section 10.1.5 (Number, Duration, and Claims Submission of HH PPS Episodes) the initial period begins with the first service delivered under that plan of care. The second subsequent period of continuous care would start on the first day after the initial period was completed.

5. Are there rules that compare the date of the HIPPS charge on the RAP to any charges on the Final Claim?

We were under the impression that these had to be matching, but in re-reading the claims manual, it seems like they are actually talking about the 'From' and 'Through' dates, not the service dates themselves.

The Statement Covers Period ('From' and 'Through' dates) on a final claim reflects the beginning and ending dates of the period covered by the claim. The 'From' date on the final claim must match the date submitted on the RAP for the period of care. For continuous care episodes final claims with dates of service on or after January 1, 2020, the 'Through' date must be 29 days after the 'From' date for a 30-day period of care.

Additionally, when the claim Admission Date matches the Statement Covers 'From' date, Medicare systems ensure that the Service Date on the 0023 revenue code line also matches these dates.

Refer to Section 40.1 (Request for Anticipated Payment (RAP)) and Section 40.2 (HH PPS Claims) of the manual revision included in Change Request 11081 (PDF, 819 KB ) for additional information.

6. Does the HIPPS code have to match between the RAP and Final claims?

Yes. This requirement has not changed. Upon submission of your final claim, the key information listed below must match between the RAP and the final claim. If these elements do not match, the claim will be moved to the Return to Provider (RTP) status/location with reason code 38107. Because the grouping of the claim will occur to determine the HIPPS code, the submitted HIPPS code will be replaced with the system-calculated code.

  • Provider number
  • 'From' date of the period of care
  • Date of admission
  • First four positions of the Health Insurance Prospective Payment System (HIPPS) code
  • Date of service billed with the HIPPS code

7. Will LUPAs be determined by the system and the provider will have no way of knowing if an episode will be processed as a no-RAP-LUPA?

Under PDGM each of the 432 case-mix groups has a threshold to determine if the period of care would receive a LUPA. The LUPA thresholds range between 2–6 visits. The table of the PDGM LUPA thresholds can be found on the CMS Home Health Patient-Driven Groupings Model web page. A claim paid as a LUPA will still create a HH period of care in Medicare systems with no RAP required, in the same way a LUPA claim creates an episode period today. But it may be a bit harder for the HHA to know in advance that an episode will be a LUPA, given the variable thresholds.

8. Do home health agencies still report supplies?

Reporting supplies under PDGM has not changed. Under the PDGM a cost per minute plus Non-Routine Supply approach is being adopted to calculate the cost of care. With this approach, the Medicare cost reports and Medicare claims will be used. This approach incorporates non-routine supplies into the base payment rate, instead of requiring a separate case-mix model as is done under the current case-mix system.

9. Will the annual outlier limitation of 10 percent remain change?
The approach to calculating outlier payment is the same as the approach used in the current system but is done on a 30-day basis instead of 60 days. The statutory requirements states that total amount of outlier payment cannot exceed 2.5 percent of total home health payments as well as a 10 percent cap on outlier payments at the home health agency level remain unchanged.

10. Would an Other Follow-up Assessment (05) (e.g., for a significant change in condition [SCIC]) ever affect the payment associated with an early (i.e., the first) 30-day period? For example, if a SCIC occurs five days after SOC (01), and an Other Follow-up Assessment (05) is completed, would that affect the early period and subsequent late period, or only the subsequent late period?

If there is a significant change in condition during the first 30-day period of care that necessitates a follow-up OASIS, the information from the follow-up OASIS would be used for the functional impairment level for the second 30-day period of care. It would not change the functional impairment level for the first 30-day period of care. However, the clinical group and the comorbidity adjustment can change from the first and second 30-day period of care as this information is obtained from the reported principal diagnosis and other diagnoses on home health claim and not the OASIS.

11. What will happen if a provider submits their claim with the Treat Auth Code when it isn’t required?

The Change Request 11081 (PDF, 819 KB) explains that on RAPs and claims with 'From' dates on or after January 1, 2020, treatment authorization codes are no longer required. The Fiscal Intermediary Standard System (FISS) will not validate (edit) for this code on 032X type of bills (TOB). When submitting a final claim (0329 TOB), adjustment (0327 TOB), or reopening (032Q TOB), FISS will zero fill the first 18 positions of the treatment authorization code field. This answer applies to home health providers who do not participate in the review choice demonstration.

12. I understand that the comprehensive assessment and updates to the HH plan of care continue on a 60-day basis. Does this mean that the recertification, comprehensive assessment and plan of care will still need to be done every 60 days, but they will bill on 30-day increments?

Yes. The 30-day period refers only to the unit of payment that is a 30-day billing cycle. This means that home health agencies will be paid for each 30-day period of care. Although we’re changing from a 60-day episode to a 30-day period, the recertification requirements, the comprehensive assessment, and the home health plan of care will continue on a 60-day basis.

For additional information, refer to the February 12, 2019, Home Health Patient-Driven Groupings Model National Provider Call CMS presentation and transcript on the CMS Home Health Patient-Driven Groupings Model web page on the CMS website.

13. Does the PDGM Occurrence Code 50, which is submitted with the date the OASIS assessment was completed (OASIS item M0090) need to match the OASIS assessment?

Yes. The Occurrence Code 50 will be used to match to the OASIS and get the functional items used for payment. Therefore, if there is a resumption of care and/or other follow up assessment prior to the start of a second 30-day period in a 60-day certification/recertification, the M0090 date from the latest resumption of care or assessment should be reported in occurrence code 50. If the matching OASIS assessment for the date reported on the claim was not yet accepted into the QIES ASAP System, the claim will be returned to the provider (RTP) because no matching assessment could be found. The claim could be resubmitted after the OASIS assessment is accepted.

14. Will a significant Symptom Control Rating change ever prompt a SCIC?

The other follow up assessment may be used by agencies when a patient experiences a significant change in condition that was not anticipated in the patient’s plan of care and would warrant an update to the plan of care. The CoP 484.55(d) does require an RFA-5 other follow up assessment to be completed when there has been a major improvement or decline in a patient’s condition that was not envisioned in the original plan of care. CMS expects agencies to have and follow agency policies that determine the criteria for when the Other Follow-up assessment is to be completed.


15. If a provider opts to submit their final claim and includes one of the Occurrence Codes, 61 or 62, whichever may be appropriate, but submits the wrong date of discharge date, what will happen?

It depends on what is wrong about the date.

If the incorrect date is earlier than it should be and falls outside the 14-day window, the claim will group as community as it goes through the Fiscal Intermediary Standard System (FISS). The claim then goes to the Common Working File (CWF), and CWF will search their records for an inpatient stay. Then:

  • If the inpatient stay is already posted to CWF, the CWF will return an edit to FISS that regroups the period of care to institutional based on the actual date

  • If the inpatient stay is not posted to CWF, the claim will continue to pay community. When the inpatient stay is received later, the Informational Unsolicited Response (IUR) from CWF will adjust the claim to regroup as institutional

  • If the inpatient stay never comes to CWF (e.g., VA hospital), the institutional stay will never be reflected unless the occurrence code date is corrected by submitting an adjustment

If the incorrect date is later than it should be and falls inside the 14-day window in error, the claim will group as institutional. At this time, the home health agency should submit an adjustment. Additional edits may be developed to edit this scenario.

16. Do HHAs still need to report the Occurrence Code 61 or 62 if the patient is discharged from a non-Medicare facility?

Yes. It would be especially important to report the appropriate occurrence code for the non-Medicare facilities, since that would be the only way to get the institutional grouping. Medicare systems would never receive an Informational Unsolicited Response (IUR) to trigger an adjustment to regroup the claim.

17. What are the billing days for PDGM, days from SOC? Prior to billing what should be present in order to bill the first 30?

Home health agencies (HHAs) will need to submit a RAP at the beginning of each 30-day period and a final claim at the end of each 30-day period. Before submitting the final claim, the HHA should ensure the OASIS assessment is completed and submitted to the iQIES system and the Request for Anticipated Payment (RAP) is submitted. Refer to the CGS Home Heath Patient-Driven Groupings Model (PDGM) Web page for CGS billing resources.

18. On Jan 1, 2020, will home health 30-day period claims need to be billed sequentially?

Currently, there is no sequential submission requirement, and there will not be any sequential submission requirement under PDGM.

Part 1 Q&A

19. What if you plan on recertifying a patient? Do you still have to drop a final every 30 days? How will this work?

With PDGM, a request for anticipated payment (RAP) and a final claim is required every 30 days.

20. How will we bill if the home health episode ends on January 12, which is overlapping the episode from PPS to PDGM?

The PDGM billing requirements apply to claims with 'From' dates of service on or after January 1, 2020. Therefore, claims with 'From' dates prior to January 1, 2020, will be submitted and processed under the HH PPS.

21. If the 61 and 62 are not required, how will you know if it is institutional or community?

The Medicare claims processing system will check for the presence of an acute/post-acute Medicare claim for an institutional stay occurring within 14 days of the home health admission on an ongoing basis.

22. Is the start of care (SOC) day 0 or 1 for submitting RAPs

Day 0.

23. The RAP does not need the treatment authorization code either with PDGM?

Correct.

24. Which OASIS time-point do we use for the M0090 dates?

We’ll be looking for providers to report the assessment completion date — again, OASIS item M0090 — for either the start of care, the resumption of care, recertification or other follow up OASIS that occurred most recently before the claim’s 'From' date.

25.  Is timely filing changing?

Timely filing requirements are not changing.

26. Do you have to submit a RAP and Final for each 30 days, i.e., for the 60-day period?

A RAP and a final claim will be submitted for each 30-day period. Duplicate of #17.

27. Signed physician orders are required to bill for a 30-day period. If a physician order is received in the first 30 days, but the order pertains to services delivered in the second 30 days, would that order (if unsigned) hold billing for the first 30 days only (date of order) or for both periods?

If it is unsigned for the second 30 days only, you can bill the first 30-day period of care. Refer to the CMS Pub. 100-04, Chapter 10 (PDF, 750 KB), Section 10.1.10.4 (Claim Submission and Processing)  for additional information.

28. Does Occurrence Code 50 need to be used on RAPs and Finals?

Occurrence code 50 is only reported on final claims.

29. Since, in some cases, we are supposed to let the RAP autocancel, will it be included in the RAP cancellation percentage tally which could result in RAP suspension?

As we transition to PDGM, this is a something the MACs will take into consideration when reviewing RAP auto-cancels. Be sure to document well.

30. Do you anticipate that there will be an increase in RAP cancellations since RAP and final claim HIPPS codes must match? The agency may not be aware of an institutional stay due to poor history and/or delays in CWF updating facility billing. I foresee that the agency may not have reliable data for submission of RAP.

It will take some internal process changes, so it may be a bit higher in the beginning. Remember, you may submit the HIPPS code you expect will be used for payment, or any valid HIPPS code. Grouping to determine the HIPPS code used for payment will occur in Medicare systems and the submitted HIPPS code on the claim will be replaced with the system-calculated code.

31. If we are in Targeted Probe and Educate (TPE), how will we be affected by PDGM?

It will basically be the same except the Additional Document Request (ADR) will be requesting documentation for 30 days instead of 60.

32. What's the difference between a second 30-day period RAP and Recert RAP after 60 days?

The second 30-day period RAP applies to the initial 60-day certification, and the recert RAP would apply to the 3rd 30-day billing period.

33. The plan of care is for 60 days. Can I bill the final 30 days prior to receiving it signed?

No, it should be signed before you bill. Refer to the CMS Pub. 100-04, Chapter 10 (PDF, 750 KB), Section 10.1.10.4 (Claim Submission and Processing) for additional information.

34. Are Q codes still needed on RAP and final claims?

Yes. You are still required to report the site of service Q-code on the final claim. Site of service codes are not required on RAPs.

35. If the HIPPS code has to match the RAP and Final Claim, does this mean we no longer change the code depending on the supplies or must we know on the RAP if there are supplies or not?

Non-routine supplies (NRS) are built into the payment under PDGM so you'll no longer have to change the code. On the RAP, submit the HIPPS code you expect will be used for payment, or any valid HIPPS code. Grouping to determine the HIPPS code used for payment will occur in Medicare systems and the submitted HIPPS code on the final claim will be replaced with the system-calculated code.

36. Clarify that the HIPPS code on the RAP can be any valid HIPPS code. Yet the final claim must have the HIPPS code that matches the RAP. How is the RAP adjusted to reflect the Final HIPPS?

Just like the current HHPPS model, the final claim will remit the full payment for the episode. Under PDGM, the same claim reconciliation process happens. When the claim is processed, Medicare systems will replace the HIPPS code with the system-calculated code, based on the combination of OASIS and claims items. The RAP payment is taken back, and the full PDGM payment is made on the final claim.

37. Will the first 30-day claim be required to be processed and/or paid prior to submitting the second 30-day?

There is no sequential billing requirement under PDGM, much like today. The only billing that must be in the system before billing the final claim is the RAP for the same billing period.

38. Will agencies be penalized due to a higher LUPA rate under PDGM? Is there a percentage that agencies would need to be aware to stay under?

No.

39. There are also approved primary codes per ICD-10 that cannot be used as primary for PDGM (to clarify), correct?

Providers should be as specific as possible with diagnosis coding under PDGM. Claims with unspecific diagnosis codes will be returned to the provider for a more specific diagnosis.

40. Do we put the 47 on the bill for a 30-day episode if we have a partial episode payment (PEP)?

There have been no changes to how condition code 47 is reported. Enter this code when the beneficiary has transferred from another home health agency (HHA).

41. What does the fifth position of the HIPPS code stand for under PDGM?

The fifth position is a placeholder for future use, required only because the field used to report HIPPS codes requires five positions.

42. Does an early/late count restart immediately if a patient is discharged in the first 30 days, or does it start at the end of the 60-day cert period?

The early period of care is the first 30 days. It does not restart, unless the patient is discharged and readmitted with a new start of care. The late period of care is the second or later 30-day period.

43. If the claim processes as a community but there is an acute stay within the 14 day but is not billed by the hospital. When will the MACs go back and re-review the claim and adjust it?

The MAC will adjust the claim and this will be reflected on your next remittance advice. The Medicare claims processing system will check for the presence of an acute/post-acute Medicare claim for an institutional stay occurring within 14 days of the home health admission on an ongoing basis.

44. There are five main case mix variables for PDGM: admission source, timing, clinical grouping, functional impairment level and comorbidity adjustment. Why are the clinical groups an important variable to PDGM?

Clinical groups are intended to reflect the primary reason for home health services. It is defined by the principal diagnosis reported on home health claim. There are twelve total groups used in the model which requires an explanation of the main reason for the home health encounter.

  • ICD-10 codes are used to determine the clinical groups
  • The 30-day period is assigned to clinical group based on principal diagnosis code on the claim
  • The average resource use of all 30-day periods within a clinical group varies across clinical groups and the payment reflects those differences
  • If a diagnosis code is used that does not fall into a clinical group (e.g., dental codes or other uncovered/invalid codes), the claim is returned to the provider for more definitive coding.

45. How are the 30-day periods grouped under PDGM?

The 30-day periods are categorized into one of three functional impairment levels (low, medium or high). The functional OASIS items that are used to create the levels are:

  1. M1800: Grooming
  2. M1810: Current ability to dress upper body safely
  3. M1820: Current ability to dress lower body safely
  4. M1830: Bathing
  5. M1840: Toilet transferring
  6. M1850: Transferring
  7. M1860: Ambulation/locomotion
  8. M1033: Risk for hospitalization

46. How does the HHA create the functional level impairments?

Determine points for the response groups to include the resource used is regressed on the OASIS items (along with other covariates from each of the PDGM groups). Regression coefficients will determine the number of points that will be applied. The points will reflect relative resource group (i.e., high intensity, greater number of points). Next, calculate the functional score for each 30-day period; the points are summed to determine an overall functional score. Lastly, assign functional impairment levels using the score. Within each PDGM diagnosis grouping, periods are split into thirds and assigned a low, medium or high functional impairment group.

47. What is comorbidity? Why is the comorbidity adjustment an important variable to PDGM?

“Comorbidity” is defined as a medical condition coexisting with to a principal diagnosis. Comorbidity is tied to poorer health outcomes, more complex medical need and management, and higher care costs.

The comorbidity adjustment category is important because it is based on the presence of a secondary diagnoses. A 30-day period may receive no comorbidity adjustment, a low comorbidity adjustment, or a high comorbidity adjustment.

48.  Can you define the no comorbidity adjustment, a low comorbidity adjustment, or a high comorbidity adjustment?

Home health 30-day periods of care can receive a comorbidity adjustment under the following circumstances:

  • No comorbidity adjustment: there is no reported secondary diagnosis that falls in either the low or high comorbidity adjustment
  • Low comorbidity adjustment: there is a reported secondary diagnosis that is associated with higher resource use
  • High comorbidity adjustment: there are two or more secondary diagnoses that are associated with higher resource use when both are reported together compared to if they were reported separately. That is, the two diagnoses may interact with one another, resulting in higher resource use.

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