The Basics of PDGM Questions:
1. What is the timing for Institutional versus Community?
To receive the higher reimbursement for being an “Institutional” referral, the patient must have been discharged from a facility in the 14 days preceding admission, or from an acute hospital in the 14 days preceding subsequent 30-day payment periods. This will be determined by claim information compiled by CMS.
Due to Axxess’ direct connection to the Medicare Common Working File, agencies can view claims data at Intake when eligibility is verified to determine if a patient is institutional or community.
2. What types of facilities are considered as “Institutional” referrals?
For the purposes of the initial home health admission, the qualifying facilities include inpatient acute care hospitals, inpatient psychiatric facilities (IPF), skilled nursing facilities (SNF), inpatient rehabilitation facilities (IRF), or long-term care hospital (LTCH). The referral source is determined by claim information rather than an OASIS response.
For the purposes of determining institutional vs. community referral source, when a patient is being resumed to care by a home health agency following transfer to a facility, only those with an inpatient acute care hospital stay in the preceding 14 days will qualify as institutional.
3. Can you speak to some examples of “Institutional/Late”? For example, how would it be classified if a patient went from the hospital to an SNF, then to the home health agency?
In this scenario, the key piece of information would be the length of stay at the SNF. For this to be classified as an institutional referral, the agency would need to complete the ROC within 14 days from the time that the patient was an inpatient at the acute care hospital. If more than 14 days lapse, it would become a community referral.
As we shared in the previous response, following a transfer and hospitalization the only facility considered as an institution is the acute care hospital.
Additionally, in this scenario, CMS has stated that agencies should discharge patients who are transferred to facilities other than acute care hospitals when the patient is not expected to return home with a home health referral. From the October 2019 OASIS Quarterly Q&As: “In the event that a patient had a qualifying hospital admission and was expected to return to your agency, you would complete RFA 6 – Transferred to an inpatient facility – not discharged from the agency. If the patient was not expected to return to your agency after this inpatient facility stay, you would compete RFA 7- Transfer to an inpatient facility-patient discharged from the agency.
However, if the patient required post-acute care in an SNF, IRF, LTCH or IPF prior to returning for home health services, CMS expects the home health agency to discharge the patient by completing the internal agency discharge paperwork and then to readmit the patient with a new Start of Care. This will allow the appropriate admission status assignment for PDGM. There is no need to update or change the transfer OASIS to reflect this discharge.
If a home health patient is admitted directly to a SNF, IRF, LTCH or IPF for a qualifying stay (stays as an inpatient for 24 hours or longer for reasons other than diagnostic testing), you would complete RFA 7 – Transfer to an inpatient facility – patient discharged from agency, then readmit the patient with a new Start of Care if they were referred for further home health services.
4. What would the second 30 days be considered for episode timing and referral source if the patient comes from a hospital in the prior 14 days?
This would be an example of “Institutional Late.” The “Institutional” component comes from the fact that the patient was discharged from the hospital in the preceding 14 days, and it would be “Late” because it is not the first 30-day billing period.
5. Is there a difference in payment if a patient falls into a Community versus Institutional category?
Yes. Patients categorized as “Community” referrals (meaning they were not discharged from an institution in the 14 days prior to the billing period), are reimbursed at a lower rate than those classified as “Institutional” referrals.
Axxess customers can easily see reimbursement for both 30-day periods by using the PDGM Analysis tool. In addition to showing reimbursement this tool will display LUPA thresholds for each of the 30-day billing periods.
6. Is Early or Late specific to my agency or does that include care provided by other agencies?
If a home health claim from the same or another HHA is found within the 60 days before the “from” date of the payment period, the Medicare payment system will automatically regroup the claim as “late.”
7. Please talk about reimbursement if a patient is seen by one agency and discharged prior to day 30, but 10 days later (in the second 30-day period) the patient is re-opened by a different agency.
If a home health claim from the same or another HHA is found within the 60 days before the “from” date of the payment period, the Medicare payment system will automatically regroup the claim as “late.”
8. When you refer to the LUPA threshold ranging from 2 to 6 for a payment period, is that the number of visits that we need for full payment or is one greater than that number?
Providing the number of visits indicated will generate full payment for the 30-day period. Payment periods barely meeting the LUPA threshold are often targeted for review such as ADRs; therefore, agencies should be confident that the care provided was skilled, reasonable and necessary, and that documentation is audit-proof.
9. Is the LUPA threshold always 6 visits for Early payment periods and 2 for Late payment periods?
No, the LUPA threshold ranges between 2 and 6, and is assigned based on the Home Health Resource Grouping per payment period. When completing a SOC, ROC, or Recertification OASIS assessment, our Home Health software will show the LUPA threshold. Often the LUPA threshold will range from 2 to 4, only 8% of the 432 possible HIPPS codes have a LUPA threshold of 5 or 6.
Axxess makes it easy to determine LUPA threshold with the use of the PDGM Analysis tool. The 30-day calendar view will assist agencies in preventing avoidable LUPAS by providing a good visualization of the end of episodes and LUPA alerts.
10. Does the LUPA threshold visit count include all disciplines, including home health aide and social work visits?
Yes. Just as is the case under PPS, billable visits made by Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Workers, and Home Health Aides all count toward the LUPA threshold.
11. Can we use Questionable Encounter diagnoses as secondary diagnosis codes?
Ungroupable Diagnoses, also known as Questionable Encounter Codes, are allowed to be used as secondary diagnoses when appropriate and necessary, according to ICD-10-CM Official Guidelines and Conventions. However, ungroupable primary diagnosis codes used in secondary diagnosis will not contribute to comorbidity adjustments.
12. Where can I find resource materials available for ICD-10 codes that will lead to Questionable Encounters and those that can be assigned to Clinical Groups?
CMS published final ICD-10-CM diagnosis codes grouper lists with the 2020 Home Health Payment Final Rule. Axxess has a wealth of resources available, including a list of questionable encounter codes available to download. These, as well as additional PDGM resources, can be accessed at: www.axxess.com/pdgm.
13. Does sequencing of comorbidities determine payment?
No, the order of the comorbid diagnosis (also called secondary diagnoses) will not affect payment since the entire claim is scrubbed for contributing diagnoses; however, specific comorbidity diagnoses (i.e. codes from certain paired comorbidity categories as outlined by CMS) must occur to create a high comorbidity adjustment.
14. If I have multiple comorbidity diagnoses on my claim, will I receive the high comorbidity adjustment?
Not necessarily. Any single diagnosis from the comorbidity categories will generate the low comorbidity adjustment. However, in order to receive the high comorbidity adjustment there must be secondary diagnoses from categories that have been paired together. An example of this would be having a code from the Behavioral 2 subgroup (such as; F31.9 Bipolar disorder, unspecified) along with a diagnosis from the Skin 3 subgroup (such as; I70.233 Atherosclerosis of native arteries of right leg with ulcerations of ankle). These high-comorbidity adjustment pairings represent higher resource utilization based on certain pathophysiologic comorbidities.
15. Does a ROC on or after January 1, 2020, generate the PDGM changes in payment?
This depends on the 60-day episode dates (from and to dates). If the ROC occurs January 1, 2020, or after for episodes that start before January 1, 2020, the payment will continue to be paid under home health prospective payment system, and therefore would not impact/adjust payment. In this scenario, PDGM payment would begin at the next episode that begins after January 1, 2020 and would be based on the recertification OASIS or ROC acting as a recert in the 5-day recert window.
However, if the ROC is completed January 1, 2020, or after for episodes beginning January 1 or after, then the ROC may be used to update the functional score for the subsequent 30-day billing period.
16. How do you manage recerts in the last week of 2019?
OASIS Recertifications completed in the final five days of 2019, for episodes where the first day of the new certification period is January 1, 2020, or later will be done using the OASIS D-1 format and will need to be completed with an artificial completion date (M0090) of 1/1/2020. These assessments will also need to be submitted to QIES on or after January 1, 2020, rather than in the final five days of December.
OASIS Recertifications completed in the final five days of 2019 for episodes where the new certification period begins prior to January 1, 2020, will continue to be paid under PPS, therefore an OASIS D assessment will be used along with the actual completion date stated in M0090.
17. On the thirtieth day, is there an assessment /re-assessment necessary to continue into the second 30-day billing period.
No additional OASIS assessments are required. It would be good agency practice to re-assess the patient and visit plan for the subsequent payment period, but it is not a requirement.
If there is a change in the focus of care (primary diagnosis), Axxess clients would use the Change in Focus Form, which will streamline clinical operations and improve compliance by updating the Care Plan and orders, if needed, through one location. In addition, the new primary diagnosis will flow seamlessly to the billing claim form to ensure maximum reimbursement.
18. Is the 30-day therapy requalifying evaluation still required?
Yes. PDGM changes are only impacting billing; all other CMS requirements are unchanged, including the requirements for 30-day therapy re-evaluations.
19. Do therapists need to continue with reassessments on the 13th and 19th visit?
No. The CMS requirements for therapy supervisory visits prior to the 13th and 19th visit was removed some time ago. The current requirement mandates therapy requalifying visits every 30 days or less while the patient is receiving therapy. The purpose of these visits is to ensure the patient continues to have a skilled need, and the goals and interventions for care remain appropriate. Each therapy discipline involved must perform these 30-day supervisory visits.
20. How will payment be affected within the PDGM structure to cover cost of wound supplies, which can be costly?
Due to the high costs associated with caring for wound patients, there is additional reimbursement attributed to the Wound Clinical grouping, as well as to the comorbidity adjustments associated with Skin diagnoses. There will no longer be a separate NRS (non-routine supply) reimbursement. Supply costs will still be reported on the CMS mandated Medicare Cost Report which will be used to determine future rates.
21. Please explain the 20% RAP.
For 2020, the RAP will no longer be paid at 60% for a SOC or 50% for subsequent episodes, but rather at 20% of the amount anticipated for the 30-day payment period. RAP submission will still be required, but there will be no RAP payment beginning in 2021.
22. Is the national standardized patient rate based off individual agency cost reports for 2019 fiscal year? How often is it reviewed?
The national standardized payment rate is updated annually and is based on figures determined by the federal government based on market baskets. These actuarial numbers are built from many data sources, including Medicare Cost Reports. Although these baskets are not usually updated annually, in most cases an annual forecast error would be applied as deemed necessary to increase or decrease expected rises in the costs of services. National per-visit discipline rates, used for calculation of LUPA payments, are historically updated using data from the Department of Labor. However, CMS has stated that Medicare Cost Report data will be used to calculate these visit costs in the future.
23. Will hospice care be affected by PDGM?
No, PDGM is strictly a revamping of the payment system for home health care.
24. Is telehealth considered a visit?
No, telehealth is not considered a visit and does not count toward the LUPA threshold.
25. Can therapy visits extend beyond the first 30-day payment period (e.g. 3W5)?
Yes, therapy visits can extend beyond the first 30-day payment period. Coverage for skilled, reasonably necessary care has not changed under the PDGM payment system.
1. What is the Notice of Admission?
A one-time notice of admission (NOA) would be filed by all home health agencies beginning in 2022 to alert the claims processing system that a beneficiary is under a home health episode of care. This will replace the RAP, which is being phased out (paid at 20% for 2020) and is intended to prevent multiple agencies providing services.
Axxess has streamlined this process and will improve agency compliance with the 2019 Final Rule through the use of the No Pay RAP option, which is already in the home health software. In addition, the No Pay RAP accommodates agencies who were certified in 2019 or later and will not receive RAP payments in 2020.
2. Is the penalty for RAPs not submitted within five days going into place in 2020, or just for the NOA not being submitted within five days in 2021?
For 2020, agencies who are newly certified in 2019 will submit RAPs but will receive no payment. Agencies who were certified prior to 2019 will submit RAPs and will receive 20% of the 30-day period payment. In 2021, all agencies will submit RAPs but will receive 0% payment for these RAPs.
There will be a non-timely submission reduction in payment amount tied to late RAP submission in 2021. This penalty will be assessed when the RAP is not submitted within five calendar days from the start of care or within five calendar days of day 31 of subsequent payment periods. This penalty will be a reduction equal to 1/30th of the 30-day period amount for each day from the Start of Care until the no-pay RAP is submitted.
Lastly, in 2022, CMS will completely phase out RAPs and will instead implement a Notice of Admission (NOA) which must be filed within five days of admission. Penalties will also be assessed if the NOA is filed later than 5 days after the SOC.
3. Is Notice of Admission scheduled to begin in 2020 or 2021? What is it and how is it done?
As part of the RAP phase-out plan, the Notice of Admission (NOA) is scheduled for implementation in 2022 and will establish the beneficiary’s agency of record, which is currently established by the filing of a RAP by the home health agency.
4. How long will agencies have to file an NOA (Notice of Admission) when this is implemented? What will happen if it is late?
Beginning in 2022, filing of the NOA will be required within five days of admission. If the NOA is filed after this required time, the agency will be penalized an amount equivalent to 1/30th of the 30-day payment per each day it was late. For example, if the NOA is not filed until day 7, the agency will not receive payment for the first 6 days.
5. How do you manage recerts?
Recertification of 60-day OASIS episodes will not change under PDGM. PDGM is a change in the payment system, but OASIS and Conditions of Participation are not affected. Recertifications will stay on the same 60-day cycles while pay periods change to 30-day periods.
Should there be a change in the patient’s focus of care between the first 30-day period and the second 30-day payment period, and no ROC or SCIC OASIS Assessment was required, the agency should have processes in place to communicate this change to the billing department and to update the coding on the claim for accurate reimbursement.
A change of Focus Form is available in the Axxess software to streamline this process and grow revenue. This form is used when the focus of care primary diagnosis changes from the first 30 days to the second 30 days. The new/changed diagnoses will automatically flow to the billing claim form. Although the 60-day OASIS remain the same it is strongly recommended that agencies use this form if they change diagnoses after a 30-day billing period not associated with a SCIC or Recert.
6. Do you have resource files where we can review the 432 groups?
CMS has information available for PDGM at: https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM.html. Axxess’ home health software provides a PDGM modeling tool which allows you to envision the PDGM impact for specific scenarios. From your dashboard, select PDGM, then PDGM Modeling Tool.
This will lead you to the Modeling Tool, which allows you to input your information to model which of the 432 groups the patient would be assigned to, as well as the case-mix weight and LUPA thresholds.
Axxess also has a wealth of additional PDGM resources that can be accessed at: www.axxess.com/pdgm.
7. Can you provide directions to the PDGM Impact Study?
The PDGM Revenue Impact Analysis tool is available to agencies using Axxess’ home health software. From your Dashboard, select PDGM, then PDGM Revenue Impact Analysis.
The resulting analysis will use your historical OASIS and visit information to display the impact that PDGM would have on your agency if no changes are made. This can be set to study the past 3 calendar years.
CMS produced a much less specific analysis of how agencies would be impacted by PDGM. That data can be accessed here: https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html. It can also be found on the Axxess PDGM Resource Page: www.axxess.com/pdgm
8. Can you provide a link to show diagnoses and corresponding thresholds?
30-day payment period LUPA levels are determined by the combined HHRG score, including referral source and timing, clinical grouping, functional deficit, and co-morbidity adjustment, rather than diagnosis. A zip file of the LUPA thresholds for the 432 distinct HHRG scores can be downloaded here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM.html
9. Can you provide a link to the Questionable Encounter Codes?
CMS has information available for PDGM at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM.html.
Axxess also has a wealth of resources, including a list of the most commonly used Questionable Encounter Codes, as well as the list of all of the Questionable Encounter Codes. These resources can be accessed for download from: www.axxess.com/pdgm.
Additionally, starting at the point of Intake and continued throughout Axxess’ home health software, the attempted use of a primary diagnosis code that would result in a Questionable Encounter will trigger an alert.
10. Is the tool for PDGM in the home health software a reliable resource to determine a patient’s LUPA threshold for each billing period?
Yes. The tools within Axxess’ home health software are accurate and up-to-date with Final Rule modifications.
11. How are we going to satisfy PDGM and RCD/PCR when a face-to-face encounter states a diagnosis such as muscle weakness?
In CMS’ home health final rule, it is stated that, “The Home Health Agency should query the certifying physician who is responsible for establishing the home health plan of care.” CMS went on to state that in regard to symptom codes that are excluded from the PDGM groupers, “We believe that by the time the individual is admitted to home health, the patient has been seen by other health care providers and a diagnosis has been established.”
Again, CMS recommends querying the physician or provider for the underlying medical diagnosis causing the symptoms so that the plan of care and treatment is specific to that disease process.
12. Do we get paid for telehealth visits?
Medicare currently does not reimburse for telehealth visits. The cost of telehealth or telemonitoring is an allowed reportable cost for the Medicare Cost Report. In some states, such as Texas, Medicaid does provide reimbursement
13. Is there a timeframe for how early a ROC or SCIC can be done in the 30-day episode to capture Clinical and Functional changes?
CMS will use the OASIS with the latest M0090 date in the prior billing period to calculate the functional level for the next 30-day period, whether that is a SOC, ROC or SCIC. Clinical category changes (i.e. the primary and secondary diagnoses) will come from claims data submitted by the agency. Therefore, the OASIS should be exported before the final bill is sent for processing so that the functional score can be calculated from the most recent OASIS Assessment. Agencies should have processes in place to notify the billing department when coding changes need to take place on the second 30-day billing claim. In Axxess, the agency can use the “Change in Focus” form to update diagnoses and this updated information will then flow to the claim.
14. Is EVV part of PDGM? Is EVV currently required for Medicare patients?
EVV is not part of PDGM. It is not currently required for Medicare patients.
15. Is recertifying patients for multiple 60-day episodes a red flag under PDGM?
The Medicare requirements for home health benefit eligibility have not changed under PDGM, (which is a change to the payment system). There is no limit on the number of episodes of care if the patient meets eligibility requirements for ‘confined to home’ and ‘reasonable and necessary skilled services’ are met, per the Medicare Benefit Policy Manual, Publication 100-2, Chapter 7.
16. What are the recommendations regarding RCD?
Review Choice Demonstration (RCD) for Home Health Services will give providers in the demonstration states an initial choice of three options:
• Pre-Claim Review (PCR)
• Post-Payment Review
• Minimal Post-Payment Review with a 25 percent payment reduction for all home health services
Once the home health agency’s full affirmation rate or claim approval rate is 90% or greater for a minimum of 10 claims or requests for the 6-month period, they may choose one of the subsequent review options:
• Start or continue participating in PCR for another six‐month period
• Selective post-payment review of a statistically valid random sample (SVRS) of claims every six months, for the remainder of the demonstration; or
• No review, other than a spot check of five percent of their claims every six months to ensure continued compliance
Although not required, agencies are highly encouraged to submit both 30-day payment periods for review at the same time. Once approved, the agency will have a Unique Tracking Number (UTN) for each of the 30-day billing periods. These UTNs will need to be added to the appropriate final claim for processing.
Updates to RCD: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Choice-Demonstration/Review-Choice-Demonstration-for-Home-Health-Services.html
17. Can NPs and PAs certify patients for home health and perform the face-to-face visit?
Mid-level providers, including nurse practitioners and physicians’ assistants, can perform the face-to-face visit in collaboration with the physician. However, the physician is the only one who can certify the patient’s eligibility for home health.
18. Do face-to-face and primary diagnosis need to match?
Yes, the face-to-face encounter documentation from the clinical encounter must be for the same reason as the primary reason for home health care. See MLN Matters SE 1436 for complete certification requirements, which included face-to-face encounter information.
19. Do all disciplines need to be started within 5 days?
It is recommended best practice for all assessing disciplines to assess the patient within the assessment period, which for Starts of Care, is 5 days from Start of Care date. This allows for collaboration between skilled disciplines for OASIS scoring as allowed by OASIS and CoP Guidance, as well as coordination of the patient’s individualized plan of care. Therapy evaluations done within this 5-day window in Axxess’ home health software will flow to the comprehensive plan of care, which means the agency will not have multiple orders awaiting signature.
20. How will a SCIC be reported to CMS? Our FIM is Palmetto.
Agency policy will determine when a patient qualified for OASIS RFA-5 Other Follow Up, which is the type used when a Significant Change in Condition is identified per Conditions of Participation definition. This OASIS type must be completed within 48 hours of the discovery of the significant change and is then exported per OASIS guidelines.
21. Can you clarify about having a different primary diagnosis on the second 30-day period? Do we need to get that diagnosis approved by the doctor and supported by the face-to-face document? Can we use that diagnosis on the Recert if it is not approved by the doctor?
Official Guidelines and Conventions are the rules that apply to diagnosis coding. These rules state that the primary diagnosis should be the primary reason for care for the encounter period. These rules also state that resolved conditions are not to be coded/included on the claim. Therefore, if the primary focus of care in the first 30-day period resolves or is different from the second 30-day period, the agency should update the coding and/or sequencing of diagnoses for the second 30-day period.
All diagnoses used on the claim must be supported by physician documentation.