Home Health & Hospice Week

Warning: Leaving off this occurrence code will result in claims returns.

The clock is steadily ticking down to PDGM’s implementation date. Make sure you’ll be ready on Jan. 1 by staying on top of new information released by Medicare.

Home health providers are in the thick of their preparations for Patient-Driven Groupings Model’s implementation, observes attorney Robert Markette Jr. with Hall Render in Indianapolis. And any that aren’t yet, should start immediately.

On Aug. 21, the Centers for Medicare & Medicaid Services held an educational call running through PDGM operational details, including critical instructions on how home health agencies can claim their rightful reimbursement for institutional periods (see Eli’s HCW, Vol. XXVIII, No. 29).

The CMS speaker also ran down these vital operational tips to make the PDGM changes “a bit less mysterious,” he said:

• RFA 05. For the first time, PDGM will use OASIS data from the Other Follow-up Assessment (Reason For Assessment 05) for case mix purposes, the CMS staffer explained in the call.

How it will work: PDGM will use the Start of Care assessment (RFA 01) for determining the functional impairment level for both the first and second 30-day periods of a new home health admission, the speaker explained. PDGM will use the Follow-up Recertification assessment (RFA 04) used for third and fourth 30-day periods. Resumption of Care (RFA 03) or Other Follow-up (RFA 05) assessments may be used for the second (or later) 30-day period.

Using RFA 05 for payment “is new for PDGM,” the CMS source highlighted.

Remember: Under PDGM, diagnosis codes on OASIS records and their related claims do not have to match.

• New FISS screen. PDGM significantly reduces how many OASIS items are used to calculate the payment category under PDGM (see story, p. 240). And now you’ll be able to more easily see exactly how they are affecting payment, the CMS speaker said.

The claims system will receive the data from the eight items from the iQIES system, and will display each of the data fields (17 total) on a new screen. The screen will list each field with an “OA” column that indicates the score drawn from the OASIS record, and an “MR” column that indicates any down- (or up-) codes from medical review by displaying the final score.

The benefits: The new FISS screen (Claim Page 43 [MAP103O]) will provide “easy reference to the data used to calculate payment groups” with “no need to look up [the] corresponding assessment,” according to the presentation. The change should make it “easier to understand what items changed as a result of review.”

The relationship between OASIS data and payment should be “more apparent” with the new screen, the CMS staffer said in the call.

Check out a mockup of the screen in the presentation slides at www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2019-08-21-HH-PDGM-Presentation.pdf — slide 16.

• Occurrence code 50. Under PDGM, the claims system will return any end of episode claim that doesn’t include occurrence code 50 indicating the assessment date, the CMS speaker emphasized. That’s because the system will use this date to match to the OASIS record in iQIES by checking M0090 (assessment completion date). “The accuracy of this date is very important,” he stressed.

Requests for Anticipated Payment (RAPs) won’t require the code.

• Early determination. Categorizing a PDGM period as early instead of late can bring a substantial pay bump — which may make it tempting to categorize all the first episodes under PDGM as early, since they will be the first episodes under the new payment system.

Nope: Not so fast, the CMS speaker cautioned. If the first PDGM billing period is not the patient’s first episode (i.e., they have adjacent, previous episodes under current HH PPS), it won’t count as early, even if it is the first PDGM episode, he explained.

Note: A recording and transcript of the call should be available in about a week at go.cms.gov/npc — scroll down to the Aug. 21 listing.