Home Health & Hospice Week

Beware LUPA dangers.

As you navigate the murky Patient-Driven Groupings Model waters, you’ll have to keep on top of a myriad of payment system revisions to stay afloat.

Payment system changes under PDGM run the gamut from major (eliminating therapy) to minor (scrapping HIPPS code reporting on OASIS), the Centers for Medicare & Medicaid Services illustrated in a Feb. 12 educational call about the payment reform model.

Here’s a list of PDGM revamps to help you chart your PDGM prep course — and avoid capsizing under the largest payment reform since PPS’s inception.

Major Changes

• Elimination of therapy from the home health case mix system.
• Switching from a 60-day episode to a 30- day billing period.
• Emphasis on diagnosis coding for payment: Two case mix factors, clinical grouping and comorbidity adjustment, will rely on codes reported on the claim.
• Addition of admission source (community versus institutional) as a case mix factor.
• Thresholds for Low Utilization Payment Adjustments will vary by case mix group, ranging from two to six visits. And with the 30-day billing period, many second or later billing periods may fall into the LUPA category.
• RAP payment elimination. As finalized in the 2019 HH PPS final rule, home health agencies certified after Jan. 1, 2019, will not receive RAP payments starting in 2020. Instead, they will receive reimbursement from their final claim only. However, they still will have to submit a no-pay RAP.

Pay Attention To These Changes Too

• No more separate supplies payments. Nonroutine supplies (NRS) payment amounts will be incorporated into the PDGM base rate.
• PDGM will use scores from two additional OASIS items, as compared to the current PPS, to calculate the case mix functional element — M1800 (Grooming) and M1033 (Risk for hospitalization). (For a list of all items used to calculate the functional impairment case mix factor, see box below.)
• HIPPS code digits will indicate different information (see box, p. 53).
• HHAs won’t need to report HIPPS codes on OASIS.
• Agencies no longer will have to report a treatment authorization code on every HH claim. This field will only be used when required by the Pre-Claim Review project, now known as the Review Choice Demonstration.
• Providers must report the OASIS completion date on every claim using occurrence code 50 and the OASIS item M0090 date. (For more billing changes, see story below.)