Home Health & Hospice Week

A larger diagnosis coding PDGM revamp is afoot.

How will recalibration of key PDGM components affect your bottom line? You’d better check out the numbers to figure it out.

“This rule touches several key areas of PDGM, from coding to LUPA threshold adjustments to OASIS point changes, that will need to be evaluated carefully by agencies,” notes consultant Angela Huff with FORVIS, the new firm formed by the merger of BKD and DHG.

In addition to a deep behavioral adjustment cut, revised LUPA thresholds, and a newly proposed cap on wage index decreases, case mix recalibration is on the table for 2023. “Annual recalibration of the PDGM case-mix weights ensures that the case-mix weights reflect, as accurately as possible, current home health resource use and changes in utilization patterns,” the Centers for Medicare & Medicaid Services says in the 2023 home health payment proposed rule. CMS recali­brated them last year too.

“For CY 2023, there are 238 groups that experience a -5% to 0% change in case-mix weights and 183 groups that experience a 0% to +5% change in weights compared to their CY 2022 case-mix weights,” CMS explains in the rule released June 17. “There are 10 groups that experience a change between +5% and +10% and one group that experiences a 10% to 12% increase in weights compared to the CY 2022 case-mix weights.”

Find it: CMS bases the recalibration on 2021 data, it notes. The new case mix weights are in Table B26 of the rule published in the June 23 Federal Register.

CMS also proposes updates to functional impairment levels. In a simulation for 2018 claims, claims were nearly evenly distributed between the Low, Medium, and High levels. In 2021, 23.2 percent were Low, 32.6 percent were Medium, and 44.2 percent were High, the rule notes.

Reminder: Responses to OASIS items M1800-M1860 and M1033 determine a patient’s functional impairment level. CMS recalibrated them last year too.

Find it: The updated OASIS functional points table and the table of functional impairment levels by clinical group for CY 2023 are listed in Tables B21 and B22 of the rule, respectively.

And finally, CMS plans to update comorbidity subgroups for CY 2023.

Reminder: “Thirty-day periods of care receive a comorbidity adjustment category based on the presence of certain secondary diagnoses reported on home health claims,” the rule explains. The categories are No, Low, and High Comorbidity Adjustment.

“We propose to update the comorbidity subgroups to include 23 low comorbidity adjustment subgroups as identified in Table B23 and 94 high comorbidity adjustment interaction subgroups as identified in Table B24,” CMS says in the rule.

The comorbidity subgroup update is part of a larger diagnosis coding revamp CMS proposes for PDGM in the rule. CMS “proposes reassignment of 320 diagnosis codes to a different clinical group when listed as a principal diagnosis, reassignment of 37 diagnosis codes to a different comorbidity subgroup when listed as a secondary diagnosis, and the establishment of a new comorbidity subgroup for certain neurological conditions and disorders,” the rule says.

That new comorbidity subgroup will be “neurological 12.” CMS says “a new neurological comorbidity subgroup to include ICD–10–CM diagnosis codes related to nondiabetic neuropathy is warranted. We identified 18 ICD–10–CM diagnosis codes for potential reassignment” to it.

Find it: “Due to the amount of diagnosis codes proposed for reassignment this year, we have posted the ‘CY 2023 Proposed Reassignment of ICD–10–CM Diagnosis Codes for HH PDGM Clinical Groups and Comorbidity Subgroups’ supplemental file on the Home Health Prospective Payment System Regulations and Notices webpage,” CMS says in the rule.

Note: Links to the files with case mix weights, LUPA thresholds, and diagnosis coding changes are at www.cms.gov/medicaremedicare-fee-service-paymenthomehealthppshome-health-prospective-payment-system-regulations/cms-1766-p in the “Downloads” section.