Home Health Patient-Driven Groupings Model
Home Health PPS Grouper Software (HHGS) Package (for claims starting 01-01-2021):
The January 2021 release of the HH PPS Grouper software (v02.1.21) is now available in the “Downloads” section of the HH Grouper Software webpage. Included in the v02.1.21 HH PPS Grouper software update are the FY 2021 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes, effective beginning January 1, 2021.
Implementation of New International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Diagnosis Codes, Effective April 1, 2020:
The Center for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) has implemented two new ICD-10-CM diagnosis codes, effective April 1, 2020:
- In response to the national emergency that was declared concerning the COVID-19 outbreak, NCHS is implementing a new diagnosis code, U07.1, COVID-19, into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and;
- In response to recent occurrences of vaping related disorders, the NCHS is implementing a new diagnosis code, U07.0, Vaping-related disorder, into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), for reporting vaping-related disorders.
Both U07.1, COVID-19 and U07.0, Vaping-related disorder are assigned to the Medication Management, Teaching and Assessment-Respiratory (MMTA-Respiratory) clinical group for purposes of case-mix adjustment under the HH PPS. Additionally, U07.1, COVID-19, is added to a new comorbidity subgroup, Respiratory 10, and will receive the Low Comorbidity adjustment under the HH PPS case-mix system effective for home health claims with From Dates on or after April 1, 2020 and included in the Home Health Patient-Driven Groupings Model (HH PDGM) Grouper software package, v01.1.20, available for download on the HH Grouper Software webpage.
Overview of the HH PPS Case-Mix Model:
CMS finalized a new case-mix classification model, the Patient-Driven Groupings Model (PDGM), effective January 1, 2020. The PDGM relies more heavily on clinical characteristics, and other patient information to place home health periods of care into meaningful payment categories. One case-mix variable is the assignment of the principal diagnosis to one of 12 clinical groups to explain the primary reason for home health services.
30-day periods are categorized into 432 case-mix groups for the purposes of adjusting payment under the PDGM. In particular, 30-day periods are placed into different subgroups for each of the following broad categories:
- Admission source (two subgroups): community or institutional admission source
- Timing of the 30-day period (two subgroups): early or late
- Clinical grouping (twelve subgroups): musculoskeletal rehabilitation; neuro/strokerehabilitation; wounds; Medication Management, Teaching, and Assessment (MMTA)
- surgical aftercare; MMTA - cardiac and circulatory; MMTA - endocrine; MMTA -gastrointestinal tract and genitourinary system; MMTA - infectious disease, neoplasms, and blood-forming diseases; MMTA - respiratory; MMTA- other;behavioral health; or complex nursing interventions
- Functional impairment level (three subgroups): low, medium, or high
- Comorbidity adjustment (three subgroups): none, low, or high based on secondary diagnoses.
In total, there are 2*2*12*3*3 = 432 possible case-mix adjusted payment groups.
- CY 2021 Home Health Final Rule
- CY 2020 Home Health Final Rule with Comment Period
- CY 2019 Home Health Final Rule with Comment Period
- MLN Matters Article MM11081- PDGM - Split Implementation (PDF)
- PDGM - Split Implementation - Change Request 11081
- Home Health Patient-Driven Groupings Model National Provider Call– February 12, 2019
- Home Health Patient-Driven Groupings Model: Operational Issues Call– August 21, 2019
- Home Health Agency Center Spotlights
- Overview of the Patient-Driven Groupings Model (PDF)
- Payments and Payment Adjustments under the Patient-Driven Groupings Model (PDF)
- Manual Updates Related to Calendar Year 2020 Home Health Payment Policy Changes, Maintenance (PDF)
- The Role of Therapy under the Home Health Patient-Driven Groupings Model (PDGM) (PDF)
- Therapy, and Remote Patient Monitoring- CR 11577 (PDF)
- For additional assistance, home health agencies may submit questions to the following email address: HomehealthPolicy@cms.hhs.gov.