Home Health & Hospice Week

MMTA expansion also affects comorbidity groups.

While some of the details have changed, the case mix steps for the Patient-Driven Groupings Model remain the same as in the proposal:

Step 1: Classify episodes into four categories based on timing and source of admission — Community Early, Community Late, Institutional Early, Institutional Late. Under PDGM, higher reimbursement would go to “institutional” 30-day episodes (those with hospital, skilled nursing facility, and inpatient rehab facility stays within 14 days of home health admission) and those that are “early” — the first or only in a series of nonadjacent episodes.

Step 2: Slot episodes into 12 clinical groupings or subgroupings based on principal diagnoses reported on the claim: Musculoskeletal Rehabilitation, Neuro/Stroke Rehabilitation, Wounds — Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care, Behavioral Health Care (including Substance Use Disorder), Complex Nursing Interventions, and seven Medication Management, Teaching and Assessment (MMTA) subgroups.

Change: The 12 groups are up from the six CMS proposed in July (which were the same proposed last year under the Home Health Groupings Model). CMS has added seven MMTA subgroups: MMTA– Surgical Aftercare, MMTA– Cardiac/Circulatory, MMTA– Endocrine, MMTA– GI/GU, MMTA– Infectious Disease/Neoplasms/Blood-forming Diseases, MMTA – Respiratory, and MMTA – Other.

Step 3: Assign episodes as Low, Medium, or High functional levels based on OASIS responses (see OASIS items, p. 312).

Step 4: Adjust for comorbidities based on secondary diagnoses. Instead of getting one adjustment level for any and all qualifying comorbidity diagnoses, PDGM will give episodes a “no,” “low,” or “high” comorbidity adjustment.

Difference: “With dividing the MMTA clinical group into subgroups … the number of comorbidity subgroups in both the low and high comorbidity adjustment is higher than as described in the … proposed rule,” CMS points out. “This more recent analysis of CY 2017 home health claims results in 13 comorbidity subgroups which would receive the low comorbidity adjustment and 34 comorbidity subgroup interactions which would receive the high comorbidity adjustment.”

The result: PDGM’s four steps result in one of 432 Home Health Resource Groups. That’s up from the proposed 216 groups, and compares to 144 case mix groups under HHGM. (Reminder: The original HHGM proposal contained 128 groups.)