2019 Final Rule – A Win for Home Health and the PDGM Workgroup

The Medicare Home Health Final Rule was issued Oct 31, 2019, and QIRT experts are feeling more positive about what the release means for home health agencies. The rule includes some positive movement in lowering the behavior assumptions percentage from 8.3% down to 4.36% increasing the unit base rate for home health from $1791.73 in the proposed rule to $1864.03 with the final rule. While this is not an elimination of the behavioral assumption altogether, it is a definite win for home health and for the PDGM Workgroup.

RAP Elimination in PDGM

As predicted, RAP elimination has been confirmed in 2021. However, split billing continues for agencies certified prior to Jan 1, 2019. Beginning January 1, 2020, RAP percentages will change to 20%  with RAP and 80% with the final bill. For newer agencies certified after January 1, 2019, no pay RAPS will be submitted.

RAPS will be submitted through 2021 and an NOA (Notice of Admission) will be required beginning in 2022.

PDGM Workgroup Requests

As you may recall, QIRT experts spearheaded a PDGM Workgroup with NAHC members several months ago, and we are pleased to see some wins on that front. Most noteworthy, the Workgroup requested many codes to be added as a valid primary diagnosis or to be recategorized and CMS granted these requests. Examples include:

Addition of symptom codes for dysphagia

R13.10 Dysphagia, unspecified
R13.11 Dysphagia, oral phase
R13.12 Dysphagia, oropharyngeal phase
R13.13 Dysphagia, pharyngeal phase
R13.14 Dysphagia, pharyngoesophageal phase
R13.19 Other dysphagia

Classified to Neuro Rehab Primary

I87.2 Venous insufficiency (chronic)(peripheral) was moved from MMTA Cardiac to MMTA Wound per workgroup recommendation, enabling agencies to capture venous stasis wounds. Additionally, this allows for the NRS and the cost of care that the wound category provides. Other additions to the MMTA Wound category include:

T81.89XA Oth complications of procedures, NEC, init
T81.89XD Oth complications of procedures, NEC, subs
T81.89XS Oth complications of procedures, NEC, sequela

Moved from MMTA Other to  MMTA Wound

T81.49XA Infection following a procedure, other surgical site, init
T81.49XD Infection following a procedure, other surgical site, subs
T81.49XS Infection fol a procedure, other surgical site, sequela

Moved from MMTA infection to  MMTA Wound

I87.313Chronic venous hypertension w ulcer of bilateral low extremity
I87.331 Chronic venous hypertension w ulcer and inflammation of R lo extremity
I87.332Chronic venous hypertension w ulcer and inflammation of L low extremity

From MMTA Cardiac to MMTA WOUND

Low comorbidity adjustments went from 12 groups of codes to 13 groups.  The Heart 10 group of codes representing Cardiac Dysrhythmias was removed. Category Endocrine 2 representing diabetes complications was added, as well as Circulatory 4 representing hypertension heart disease and chronic kidney disease.

High comorbidity adjustment removed #8, #13, #23 and #24 comorbid combinations and added a combination for Cerebral 4 and Neuro 10 combination. This lowers the interaction subgroups from 34 to 31 subgroups for CY2020.

Support from QIRT

In the new payment model, accurate coding and OASIS, coupled with fast turnaround times will make all the difference for the success of an agency. QIRT experts are available to help agencies prepare for the transition. For more information, visit our website or email QIRT today.

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