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CMS Releases Revised and Additional Instructions for Billing Under PDGM

The Centers for Medicare & Medicaid Services (CMS) released Transmittal 4378/Change Request (CR) – Home Health (HH) Patient-Driven Groupings Model (PDGM) – Revised and Additional Manual Instructions. This transmittal revises additional sections of the CMS Claims Processing Manual, Chapter 10, to support the implementation of the Home Health Patient-driven Groupings Model (HH-PDGM) and creates new sections to describe the HH-PDGM program.

Home health providers will find Section 10.1.23 – Changes in a Beneficiary’s Payment Source – of particular interest.  This section addresses the following situations:

  • Payment Source Changes From Medicare Advantage (MA) Organization to Original Medicare
  • Payment Source Changes From Original Medicare to MA Organization
  • Payment Source Changes Involving Medicaid

This section explains what should be coded on claims for these situations as well as addresses corresponding OASIS completion requirements.

Section 80 deals with the Home Health Grouper program.  The Home Health Resource Group (HHRG) used to pay home health services billed on TOB 032x are determined by the HH Grouper program. HHRGs are represented on claims in the form of HIPPS codes. Like the Home Health Pricer, the Home Health Grouper is a module within Medicare claims processing systems. The home health agency sends a HIPPS code on the claim, using revenue code 0023. Medicare systems combine claim data and OASIS data and send the data to the Home Health Grouper to determine the HIPPS code used for payment. The HIPPS code from the Grouper replaces the provider-submitted HIPPS code on the claim and is then sent to the Home Health Pricer for payment calculations.

Medicare claims processing systems must send an input record to Grouper for all claims and most adjustments. RAPs and medical review or other program integrity contractor adjustments are not sent to the Grouper. The Grouper will return an output record to the shared systems whenever an input record is sent.

No part of the Grouper logic is required to be incorporated into an HHA’s billing system in order to bill Medicare, unless the HHA chooses to do so to assist their accounts receivable functions. The following is presented for A/B MACs (Home Health & Hospice) and as information for the home health agencies, in order to help home health agencies understand how their HH claims are processed.  The required data and format for the Home Health Grouper input/output record for periods of care beginning on or after January 1, 2020 are detailed in this update.

This Transmittal is only one of CMS’ releases related to billing under PDGM.  

For questions on this article, please contact Anne Shelley at (National Association for Home Care & Hospice)

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