Home Health & Hospice Week

Six clinical groups won’t accurately reflect resource need, commenter argues.

Diagnosis coding for home health patients is at the root of some major problems industry members pointed out with the Home Health Groupings Model, according to their comment letters on the HH PPS 2018 proposed rule.

Reminder: Case mix Step 2 of HHGM slots episodes into six clinical groupings based on principal diagnoses reported on the claim: Musculoskeletal Rehabilitation; Neuro/Stroke Rehabilitation; Wounds — Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care; Complex Nursing Interventions; Behavioral Health Care; and Medication Management, Teaching and Assessment (MMTA). (See the six steps of determining case mix under HHGM in Eli’s HCW, Vol. XXVI, No. 27-28).

“The proposed six clinical groupings based on primary diagnosis alone are very concerning,” says Lisa Haglund with Sunshine Home Health Care in Spokane, Washington. “This does not accurately reflect the degree of care that any patient may need. As certified in medical coding, countless times I have difficulty, as also do the clinicians, deciding on singular primary focus of care, and extremely rarely do.”

For example: “If the Clinical group for a patient falls under [MMTA] … on a patient with heart failure as a primary diagnosis, this patient often needs a large amount of therapy to assess and teach to their activity levels for safety, education regarding durable medical equipment in order that their limited resources and energies, and endurance are maximized. Because they may fall into the [MMTA] category, providing therapy services to these patients may be cost-prohibitive with poorer outcomes and risk of greater hospitalizations.”

HHGM Underestimates Comorbidity Impact

Reminder: Step 4 of the HHGM case mix system adjusts payment for comorbidities based on a secondary diagnosis. But HHGM’s attempt to account for patients’ conditions this way falls far short, commenters claimed.

“CMS proposes that if a period had at least one secondary diagnosis reported on the home health claim that fell into one of the 15 subcategories, that period would receive a comorbidity adjustment to account for higher costs associated with the comorbidity. The comorbidity adjustment amount would be the same across all of the subcategories. A period would receive only one comorbidity adjustment regardless of the number of secondary diagnoses reported on the home health claim,” recaps Avera@Home and its parent Avera Health in Sioux Falls, South Dakota.

The problem: “Avera home health members, in many cases, actively participate as a part of a continuum and care for older adults with multiple comorbidities. Overall Medicare spending increases with the number of chronic conditions, so it is counterproductive for the HHGM to only allow one comorbidity adjustment regardless of the number of secondary diagnoses reported on the home health claim,” the health system says.

Marcie Ganson in Illinois elaborates on this flaw. “Many of our agency’s home care patients have multiple orthopedic, neurologic, cardiovascular, pulmonary, and endocrine diseases. It is common for our patients to have arthritis, joint replacements and/or fractures, Parkinson’s and/or Alzheimer’s Disease, hypertensions, COPD, and diabetes, and to be on over 25 prescription medications,” Ganson told CMS. “Research has identified the many challenges of and resources needed for supporting chronic disease management and adhering to multiple clinical practice guidelines for multiple diseases. With many of our home care patients, we have to address all this while also addressing new or exacerbated pain and functional mobility, self-care, and communication limitations. I am afraid that the proposed reimbursement system will financially penalize agencies that accept the most frail and medically-needy patients, and particularly those needing rehabilitation.”

Haglund adds, “most patients that I code and review their files have several comorbidities that impact their care [and] their ability to regain function, and these require additional resources. The proposed model would make it more difficult for home health agencies to care for the more complex patient unless the reimbursement categories will account for the more intensive care.”

Using the same comorbidity adjustment amount across all of the subcategories is also a problem. “Each comorbidity may have a different impact on health outcomes and should be accounted for in any comorbidity adjustment,” Avera urges.