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Additional Clarity from CMS Regarding PDGM

October 31, 2019

 

During our recent PDGM Action Items webinar (you can find a link to that recording here), several attendees had questions around interpretive guidelines. CMS has provided more clarity and we wanted to make sure we relayed that information.

 

Here are some of the most relevant questions from CMS’s PDGM FAQ that relate best to our attendees’ questions:

 

FAQ: Please clarify if M1021 and M1023 should include all known diagnoses as stated in the Interpretive Guidelines for Home Health Agencies or continue to report only current diagnoses as it is currently defined in the OASIS Guidance Manual for M1021 and M1023? Specifically clarify if M1021 and M1023 should include known diagnoses that are resolved or diagnoses that do not have the potential to impact the skilled services ordered? 

 

CMS Answer: OASIS guidance states that M1021 Primary Diagnosis and M1023 Other Diagnoses should include only current diagnoses actively addressed in the Plan of Care or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis even if not the focus of any home health treatment itself. M1021 and M1023 should exclude resolved diagnoses or those that do not have the potential to impact the skilled services provided by the HHA (OASIS Guidance Manual). This description is in accordance with assigning primary and other diagnoses from the ICD-10-CM Official Guidelines for Coding and Reporting. The Interpretive Guideline for HH CoP §484.60(a)(2) state that the individualized plan of care must include the following:

  • All pertinent diagnoses; … further explaining that “All pertinent diagnoses” means all known diagnoses. For M1021 and M1023, continue to report only current medical diagnoses actively addressed in the plan of care or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis even if not the focus of any home health treatment itself. Include comorbidities, a condition coexisting with the principal diagnosis that can affect the Home Health Plan of Care in terms of services provided and time spent with patients. Exclude other resolved diagnoses or those that do not have the potential to impact the skilled services provided by the HHA. 

 

FAQ: With PDGM, diagnosis grouping will come from the diagnoses listed on the claim. I understand that that the OASIS and claim diagnoses codes may not always match. There are six spaces for diagnosis on OASIS and 25 spaces for diagnosis on the claim. Can I include additional diagnosis on the claim after matching the first six from my OASIS? What kind of diagnoses may I list on the claim? Must they meet the definition of a primary and other diagnosis found in Chapter 3 of the OASIS Guidance Manual, M1021 and M1023? Or may I include any pertinent diagnosis, which means any known diagnosis, per the HH CoP 484.60(a)(2) Interpretive Guidelines?

 

CMS Answer: Any additional diagnosis listed on the claim should follow the OASIS definitions for primary and secondary diagnosis found in the OASIS Guidance Manual. Include only current diagnoses actively addressed in the plan of care or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis even if not the focus of any home health treatment itself. Exclude resolved diagnoses or those that do not have the potential to impact the skilled services provided by the HHA, even if they are known/documented diagnoses. Adhere to the ICD-10-CM Official Guidelines for Coding and Reporting when assigning ICD-10-CM diagnosis codes. Note that the CY2019 Home Health Final Rule has stated that, “Because ICD–10 coding guidelines require reporting of all secondary diagnoses that affect the plan of care, we would expect that more secondary diagnoses would be reported on the home health claim given the increased number of secondary diagnosis fields on the home health claim compared to the OASIS item set.”

 

FAQ: I was recently instructed that with PDGM, the diagnoses used to determine payment will come from the claim and these diagnoses may not necessarily match the diagnoses listed in M1021 and M1023 on OASIS. Please clarify. 

 

CMS Answer: For case-mix adjustment purposes, the principal diagnosis reported on the home health claim will determine the clinical group for each 30-day period of care. In Change Request 11272, CMS has updated billing instructions to clarify that there will be no need for the HHA to complete an ‘‘Other follow-up’’ assessment (RFA 05) just to make the diagnoses match. Therefore, for claim ‘‘From’’ dates on or after January 1, 2020, the ICD–10–CM code and principal diagnosis used for payment grouping will be from the claim rather than the OASIS. As a result, the claim and OASIS diagnosis codes will no longer be expected to match in all cases. Additional claims processing guidance, including the role of the OASIS item set will be included in the Medicare Claims Processing Manual, chapter 10.

 

FAQ: What happens if an HHA is not aware of an institutional discharge when they submit the claim?

 

CMS Answer:

  1. If the inpatient claim has been processed by Medicare before the HH claim is received, Medicare systems will identify it and group the HH claim into an institutional payment group automatically.

  2. If the inpatient claim has not been processed yet when the HH claim is received, Medicare systems will group the HH claim into a community payment group ‒ When the inpatient claim is processed later, Medicare systems will automatically adjust the paid HH claim and pay it using an institutional payment group instead.

  3. Automatic adjustments to change community payment groups to institutional will be identified on the remittance advice:

    1. Type of Bill (TOB) 032G ‒ Claim adjustment reason code (CARC) 186

    2. Remittance advice remark code (RARC) N69

 

Based on our work with home health and hospice providers, we predict there will be many adjustments to claims at the End of the Episode. Many facilities are not timely with billing, which will cause claim adjustments. This is an area to watch closely and understand changes in revenue -- both positive and negative.

 

If you missed CMS’s resource referenced in this blog, “Home Health Patient-Driven Groupings Model: Operational Issues” you can find it here.

 

If you have any further questions that we at Maxwell can help you with, don’t hesitate to reach out. We love hearing from you.

 

 

 

 

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