Take A Look At Latest PDGM Clarifications from CMS

One piece of information you may find surprising from an Aug. 21 Centers for Medicare & Medicaid Services education call, “Home Health Patient-Driven Groupings Model: Operational Issues,” regards payment hold time.

As always, Medicare contractors will hold home health agency claims between Jan. 1 and when system changes get installed — this year, Jan. 6. The period of time is usually shorter than the 14-day payment floor for claims anyway.

The earliest PDGM Requests for Anticipated Payment and End of Episode claims would process would be Jan. 6. But CMS has to test the new system, and if glitches that prevent correct payment appear, RAPs and claims will hold as long as is necessary to fix them, the CMS speaker indicated in the call.

The “key word” is “testing,” the staffer emphasized. CMS “can’t say for certain” when the new PDGM claims will release, he added.

This is yet one more reason for HHAs to draft a cash flow backup plan for PDGM, experts urge.

Check out more information CMS revealed in the call:

  • Unlike with hospice claims, home health claims will have no sequential billing requirement, the CMS source confirmed. That means agencies can bill a subsequent episode’s RAP before billing the prior episode’s EOE claim, which might come in handy if a physician is dragging her feet on furnishing or correcting required documentation.
  • Under PDGM, only eight OASIS items will contribute to case mix: M1033 (Hospitalization Risk), and M1800, M1810, M1820, M1830, M1840, M1850, and M1860 (current functional levels). If you make changes to any other OASIS items besides those eight, you don’t need to adjust your related claim, the CMS speaker indicated in the call.
  • Periods where Medicare is the secondary payor will count toward the early/late designation for case mix (with early paying more), but Medicare Advantage periods will not.
  • While the requirement for primary diagnosis codes to match on the OASIS and claim is going away under PDGM, the overall OASIS matching edit is not. Starting after 40 days from the M0090 date, the Medicare claims system will return a claim when no matching edit is identified in the new iQIES system. (PDGM and iQies are not actually related, they just happen to both be launching at the same time.)
  • Likewise, the methodology for calculating Partial Episode Payment adjustments will stay the same, just within the new shorter 30-day timeframe. So if you discharge a patient on day 21 of an episode, and readmit them on day 27, the first episode payment will be prorated at a rate of 21/30, with a new episode starting day 27 (with a late designation).

Source: CMS.gov