HH05: Home Health Claims – 60 Day Episode Life Cycle/30 Day Periods/PDGM Copy
60 Day Episode Life Cycle / 30 Day Periods / PDGM
60-Day Episode Rate
The law requires the 60-day episode to include all covered home health services, including medical supplies, paid on a reasonable cost basis. That means the 60-day episode rate includes costs for the six home health disciplines and the costs for routine and nonroutine medical supplies.
The six home health disciplines included in the 60-day episode rate are:
1. Skilled nursing services; 2. Home health aide services; 3. Physical therapy; 4. Speech-language pathology services;
5. Occupational therapy services; and
6. Medical social services.
30-Day Periods of Care under the PDGM
While the unit of payment for home health services will be a 30-day period starting on January 1, 2020; there are no changes to timeframes for re-certifying eligibility and reviewing the home health plan of care, both of which still need to occur every 60-days (or in the case of updates to the plan of care, more often as the patient’s condition warrants).
Because the unit of payment is now 30-days, instead of 60-days, HHAs may have more frequent contact with the certifying physician to communicate any changes in the patient’s condition to ensure that home health payment is adjusted to account for those changes.
Furthermore, the certification and the home health plan of care must be signed timely by the certifying physician because HHAs will submit a final claim with each 30-day period of care and need this important signed documentation in order to bill for home health services.
Home health services are not limited to a single 30-day period of care. An individual can continue to receive home health services for subsequent 30-day periods as long as the individual continues to meet home health eligibility criteria.
Under prior payment systems, as well as PPS, the volume of services provided has played a key role in determining payment
Under PDGM, the focus is on the characteristics of the patient
New HIPPS Code Format
_1-4_ _A-L_ _A-C_ _1-3_ _1_
*Only 1 payment characteristic is coming from the OASIS and that is functional level
Overview of the Patient-Driven Groupings Model
Figure 1 provides an overview of how 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.
Under the PDGM, each 30-day period is classified into one of two admission source categories – community or institutional – depending on what healthcare setting was utilized in the 14 days prior to home health admission.
Late 30-day periods are always classified as a community admission unless there was an acute inpatient hospital stay in the 14 days prior to the late home health 30-day period.
A post-acute stay in the 14 days prior to a late home health 30-day period would not be classified as an institutional admission unless the patient had been discharged from home health prior to a post-acute stay.
Timing of the 30-Day Period:
Under the PDGM, the first 30-day period is classified as early. All subsequent 30-day periods (second or later) in a sequence of 30-day periods are classified as late. A sequence of 30-day periods continues until there is a gap of at least 60-days between the end of one 30-day period and the start of the next. When there is a gap of at least 60-days, the subsequent 30-day period is classified as being the first 30-day period of a new sequence (and therefore, is labeled as early).
Under the PDGM, each 30-day period is grouped into one of twelve clinical groups based on the patient’s principal diagnosis as reported on home health claims. The reported principal diagnosis provides information to describe the primary reason for which patients are receiving home health services under the Medicare home health benefit.
Table 1 below describes the twelve clinical groups.
These groups are designed to capture the most common types of care that Home Health Agencies (HHAs) provide. While there are clinical groups where the primary reason for home health services is for therapy (for example, Musculoskeletal Rehabilitation) and other clinical groups where the primary reason for home health services is for nursing (for example, Complex Nursing Interventions), these groups represent the primary reason for home health services during a 30-day period of care, but not the only reason for home health care.
Home health remains a multidisciplinary benefit and payment is bundled to cover all necessary services identified on the individualized home health plan of care.
Functional Impairment Level:
The PDGM designates a functional impairment level for each 30-day period based on responses to the OASIS items in Table below:
Responses that indicate higher functional impairment and a higher risk of hospitalization are associated with higher resource use and are therefore assigned higher points. These points are then summed, and thresholds are applied to determine whether a 30-day period is assigned a low, medium, or high functional impairment level.
The PDGM includes a comorbidity adjustment category based on the presence of certain secondary diagnoses (for example, congestive heart failure) associated with increased resource use. Depending on a patient’s secondary diagnoses, a 30-day period may receive 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:
- Low comorbidity adjustment: There is a reported secondary diagnosis that is associated with higher resource use, or;
- 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.
- No comorbidity adjustment: A 30-day period would receive no comorbidity adjustment if no secondary diagnoses exist or none meet the criteria for a low or high comorbidity adjustment.