Home Health Patient Driven Groupings

Home Health Patient Driven Groupings

The Centers for Medicare and Medicaid (CMS) announced a new Patient Driven Groupings Model for Home Health that replaces the Prospective Payment System effective January 1, 2020.   The PDGM uses 30-day periods categorized into many more case mix groupings that the prior PPS system, and these are categorized into subgroups.

To elaborate, a brief comparison of the PPS and PDGM model is as follows:

Old PPS HHRG Model for Home Health – 153 Distinct HHRGs

Under the Prospective Payment System (PPS), the Home Health Resource Group (HHRG) has several components including functional domain and service utilization domain. A patient assessment was performed and scored.  The result of the assessment groups categorized the patient into one of 153 Home Health Resource Groups (HHRGs). These scored correlated to episodes. For example, a 58 day episode yields two new segments: a initial 30 day period (days 1-30) and a second 28 day period (days 31- 28)

New Home Health Patient Driven Grouping (PDGM) Model for Home Health – 432 Distinct HHRGs

CMS finalized a case-mix classification model called Patient-Driven Groupings Model (PDGM), effective January 1, 2020. PDGM focuses on clinical characteristics, and secondarily other patient data to correlate home health episodes of care into payment categories.  As noted, PDGM uses 30-day periods categorized into 30 day subgroups are as follows:

  • Admission source (two subgroups), which can be either
    • (a) community admission source or
    • (b) institutional admission source
  • Timing of the 30-day period (two subgroups), which can be either
    • (a) early or
    • (b) late
  • Clinical grouping into one of twelve subgroups, which can be:
    1. musculoskeletal rehabilitation;
    2. neuro/stroke rehabilitation;
    3. wounds;
    4. medication management, teaching, and assessment (MMTA) – surgical aftercare;
    5. MMTA – cardiac and circulatory;
    6. MMTA – endocrine;
    7. MMTA – gastrointestinal tract and genitourinary system;
    8. MMTA – infectious disease, neoplasms, and blood-forming diseases;
    9. MMTA – respiratory;
    10. MMTA- other;
    11. behavioral health;
    12. or complex nursing interventions
  • Functional impairment level (three subgroups) which can be:
    • (a) low,
    • (b) medium, or
    • (c) high
  • Comorbidity adjustment (three subgroups) based on secondary diagnoses, which can be
    • (a) none,
    • (b) low, or
    • (c) high

Therefore the home health Patient Driven Groupings model results in a permutation of possible case mix adjusted groups, calculated as 2 admission sources x two timing, x 12 clinical groupings, x three functional impairment levels, x three comorbidity adjustments = (2*2*12*3*3) = 432 distinct case-mix adjusted payment groups.

OASIS Assessment Components

The OASIS items contributing to functional level are:

  1. M1033: Risk for Hospitalization
  2. M1800: Grooming
  3. M1810: Dressing Upper Body
  4. M1820: Dressing Lower Body
  5. M1830: Bathing
  6. M1840: Toilet Transferring
  7. M1850: Transferring
  8. M1860: Ambulation/Locomotion

CMS tracks and reports HHA Agency Level impact information for calendar year 2019 vs projected percent changes under PDGM using the CMS Certification Number (CCN).  Based on a therapy visit ratio, number of 60-day episodes, 30-day periods, CMS published estimated PDGM payments and the payment change percent projection.

CMS. 2017 Methodology for HHRGs.  See https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2017-01-18-HH-Presentation.pdf

CMS. 2020 PDGM.  See https://www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/HomeHealthPPS/Downloads/Overview-of-the-Patient-Driven-Groupings-Model.pdf

Related Topics

Medicare Skilled Nursing 2020 Final Rule

Expert Rebuttal to Life Care Plans that Include Home Health and Attendant Care

Skilled Nursing Dependent on Resource Utilization Groups (RUGs)

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Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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