Home Health & Hospice Week

MACs, CMS, and NAHC are all offering a helping hand in HHAs’ time of need.

Home health agencies have been spending months preparing for the paradigm-shifting new payment system to take effect Jan. 1. With the Patient-Driven Groupings Model almost here, HHAs can take advantage of this newly released resources to smooth the wrinkles in their transition to the new payment model:

• Palmetto GBA PDGM job aid. A two-page Home Health Prospective Payment System (HH PPS) vs Patient-Driven Groupings Model (PDGM) Job Aid from the HHH Medicare Administrative Contractor walks through the differences between the two payment systems in a concise two-page format. The tool contrasts Request for Anticipated Payment billing rules, case mix factors, and HIPPS code digits.

Pointer: “HHAs may submit the HIPPS code they expect will be used for payment if they run grouping software. If not, they may submit any valid HIPPS code,” the job aid explains. “Grouping to determine the HIPPS code used for payment will occur in Medicare systems and the submitted HIPPS code on the claim will be replaced with the system-calculated code.”

Find at: www.palmettogba.com/Palmetto/Providers.Nsf/files/HH_PPS_vs_PDGM_Job_Aid.pdf/$File/HH_PPS_vs_PDGM_Job_Aid.pdf.

• CGS PDGM website updates. Just in time for PDGM implementation, MAC CGS has updated and added multiple items on the portion of its website dedicated to the new payment system. New and updated documents include a Final Claim Timeliness Calculator, step-by-step instructions for submitting RAPs and final claims, and recordings of the MACs’ recent educational webinars on PDGM.

Pointer: “If the final claim is not received 90 days after the start date of the period of care or 60 days after the paid date of the RAP (whichever is greater), the RAP payment will be cancelled automatically by the Fiscal Intermediary Standard System (FISS),” CGS reminds on its timeliness calculator page. That is down from the current 120 days from the start date, although the 60 days after the RAP paid date remains the same.

Find at: Links to the billing instructions are at www.cgsmedicare.com/hhh/education/materials/pdgm.html, the timeliness calculator is at www.cgsmedicare.com/medicare_dynamic/j15/pdgm_final_claim_calc/pdgm_final_claim_calc.aspx, and links to register and listen to the Nov. 21 and Dec. 5 PDGM recordings are at www.cgsmedicare.com/hhh/education/recorded_webinars.html.

• NAHC PDGM Physicians Toolkit. Getting physicians on board the PDGM train is one of agencies’ biggest challenges of the new payment system, experts predict. Get some assistance from the National Association for Home Care & Hospice’s PDGM Physicians Toolkit, which includes brief, physician-tailored educational materials on the payment system, as well as a complete list of ICD-10 codes that are not valid under PDGM — meaning claims will return to provider if the codes are listed as the principal diagnosis on the claim.

Pointer: “The complete unacceptable diagnoses list for Medicare home health care is 620 pages and contains more than 29,000 ICD-10 diagnoses code and descriptions,” NAHC says in the exhaustive list included in PDF format. “Many of the diagnoses on the list would never be listed as a primary diagnosis for home health patients from a clinical perspective. The list might be helpful to determine if a particular diagnosis will not be accepted for Medicare home health patients under PDGM.”

Find at: NAHC’s toolkit is publicly available at www.nahc.org/resources-services/regulatory-operational-resources/pdgm-physicians-toolkit.

• MLN Matters articles. If you missed the Centers for Medicare & Medicaid Services’ transmittal clarifying complicated PDGM billing scenarios last month, now’s the time to circle back. A MLN Matters article explaining Change Request 11527 contains key billing information.

Pointer: “For services after January 1, 2020, discharge is not required if the beneficiary has an inpatient stay that spans the end of the first 30-day period of care in a certification period,” CMS instructs. “The HHA should submit the RAP and claim for the period following the discharge as if the 30-day periods were contiguous — submit a From date of day 31, even though it falls during the inpatient stay and the first visit date that occurs after the hospital discharge. Medicare systems will allow the HH claim to overlap the inpatient claim for dates in which there are no HH visits.” On the other hand, “discharge should be made at the end of the 60-day certification period in all cases if the beneficiary has not returned to the HHA,” CMS confirms.

Find at: The MLN Matters article at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11527.pdf contains a summary of and a link to the transmittal, as well as links to other MLN Matters articles addressing PDGM.