Home Health & Hospice Week

Thirty-day billing period base rate 55.6 percent of 60-day rate.

It soon will be time for the rubber to hit the road when it comes to the Patient-Driven Groupings Model. Does your agency have what it takes under the hood to go the distance under the payment shakeup?

The Centers for Medicare & Medicaid Services kicked off its PDGM education campaign with a Feb. 12 MLN Matters educational call reviewing the payment reform plan that was finalized in the 2019 HH Prospective Payment System final rule.

The information on the call “was a reiteration of what CMS has already issued either though the final payment rule or a CMS transmittal,” the National Association for Home Care & Hospice’s Mary Carr tells Eli.

CMS officials reviewed the PDGM basics, including the four case mix steps of the system using five major variables: admission source, timing, clinical grouping, functional impairment level, and comorbidity adjustment (see flow chart, below).

“These changes represent the largest overhaul of the payment methodology since the implementation of the home health prospective payment system on Oct. 1, 2000,” a CMS staffer told attendees.

PDGM Case Mix Steps

The CMS presenter laid out from where the data will come for each element. The admission source, timing, clinical grouping principal diagnosis codes, and comorbidity adjustment secondary diagnosis codes all will come from claims data, she specified. Only the functional impairment level data will come from the OASIS assessment.

Consider This Episode Base Rate Estimate

One of PDGM’s biggest changes is implementing 30-day billing periods, versus the current 60-day episode. Home health agencies have been wondering what a 30-day episode payment rate will look like — and hoping it wouldn’t merely cut the current 60-day episode rate in half.

It appears CMS plans to stick with the estimates it included in its 2019 proposed and final rules. “To provide HHAs with a sense of the payment amount for a 30-day period of care, we estimated that if the PDGM was implemented in CY 2019, the estimated national, standardized 30-day payment would be $1,753.68,” CMS said in the call.

However, “this 30-day payment amount will be updated for CY 2020,” CMS points out.

The figure CMS offers is 55.6 percent of the CY 2019 PPS base rate of $3,154.27. And it’s reduced by the 6.42 percent behavioral adjustment cut, notes M. Aaron Little with BKD in Springfield, Missouri.

The 30-day rate is “as expected, because it’s what was used in the proposed rule,” Little tells Eli. But hopefully the behavioral adjustment “is going to either be removed … or at the very least reduced by 2020” (see related box, p. 51).

Without that 6.42 percent cut, the 30-day rate would be $1,873.91, according to the proposed and final rules.

HHAs will have to wait for the home health proposed rule for 2020, usually issued around July 4, for a more accurate 30-day base rate figure. And even that may be tweaked in the final rule, usually issued in early November.

Run Your Numbers

Agencies trying to wrap their minds around what their reimbursement will look like under PDGM can use the 30-day base rate figure plus CMS’s sample grouper tool.

“I really do recommend that you download this interactive grouper tool to see what the case mix weights under the PDGM would be for your respective patient populations,” a CMS official urged in the call.

The presentation offered several examples of how to use the grouper, with step-by-step instructions.

Tip: Make sure you put in enough visits to exceed the Low Utilization Payment Adjustment (LUPA) threshold, or the tool will give you a warning message instead of the case mix weight.

Note: The link to the slide presentation for the call is at www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2019-02-12-PDGM.html. A recording and transcript of the call should be up on the site in about two weeks, according to CMS.