Home Health & Hospice Week

Plus: Get to know big comorbidity group revamp.

Data revealed in the recent proposed home health payment rule for 2022 shows why you’ll see a big change to PDGM’s functional impairment calculation starting Jan. 1, if the rule is finalized as-is.

The proportions of 30-day Patient-Driven Groupings Model periods by functional impairment level swung markedly from 2018 to 2020, the Centers for Medicare & Medicaid Services shows in the proposed rule published in the July 7 Federal Register. “Low” periods dropped from 33.9 percent in 2018 to 25.6 percent in 2020; “Medium” periods fell modestly from 34.9 percent to 32.7 percent in the same time period; and “High” periods shot up from 31.2 percent to 41.7 percent. (CMS uses simulated 30-day periods in pre-PDGM 2018 by splitting 60-day episodes from that year into two.)

“The three functional impairment levels of low, medium, and high were designed so that approximately one-third of home health periods from each of the clinical groups fall within each level,” CMS points out in the rule. Presumably as a result, CMS is proposing to “update the functional points and functional impairment levels by clinical group” based on the data, the rule says.

“The scoring of the functional points, and corresponding decrease in a lot of the thresholds was surprising,” says consultant J’non Griffin, owner of Home Health Solutions in Carbon Hill, Alabama.

Another surprise was a reshuffle of comorbidity groups. CMS found that comorbidity groups, which are based on the up to 24 secondary diagnoses listed on a claim, saw significant swings too. The percentage of “High” periods spiked from 9.2 percent in 2018 to 14.0 percent in 2020; “Low” periods increased modestly from 35.3 percent to 36.9 percent in that time period; and “No” periods dropped from 55.6 percent to 49.2 percent.

Reminder: Under PDGM, for the “Low” adjustment, there is a reported secondary diagnosis on the home health-specific comorbidity subgroup list that is associated with higher resource use. For the “High” adjustment, there are two or more secondary diagnoses on the home health-specific comorbidity subgroup interaction list that are associated with higher resource use when both are reported together compared to if they were reported separately. The “No” group contains no such diagnoses.

“For CY 2022, we propose to update the comorbidity subgroups to include 20 low comorbidity adjustment subgroups … and 85 high comorbidity adjustment interaction subgroups,” CMS says in the rule.

The low comorbidity adjustment subgroups have both removals and additions, and the high comorbidity adjustment subgroup pairs more than double for 2022, notes Simione Healthcare Consultants in online analysis of the proposed rule.

Resource: You can find the new comorbidity groups in Tables 15 and 16 in the rule at www.govinfo.gov/content/pkg/FR-2021-07-07/pdf/2021-13763.pdf.

“The most surprising thing to me was the expansion of the low and high comorbidity categories, while eliminating others that were there,” Griffin tells AAPC.

“We invite comments on the proposed updates to the low comorbidity adjustment subgroups and the high comorbidity adjustment interactions for CY 2022,” CMS specifies in the rule. The deadline to submit comments is Aug. 27.