On November 28, 2012, the Centers for Medicare and Medicaid Services (CMS) released the 2013 home health Grouper (PPS payment logic) which includes the adjustments required by the Home Health PPS rate changes for 2013.  These changes will impact home health agency payments for OASIS submissions with an assessment date on or after January 1, 2013.

An extremely significant change to the Grouper is the restriction of the scoring of codes reported in the M1024 payment slot to a defined list outlined in Table 25 of the home health PPS rule for 2013. Although other resolved issues may be entered in M1024 for data collection purposes, only fracture codes will be granted case-mix points.  CMS believes that agencies will be reimbursed for care for other resolved issues through clinical points.

In addition, the Grouper will permit more codes to act “as if” primary when directly preceded by a designated aftercare V code.  The Grouper documentation includes a list of V codes that will promote diagnosis codes to score primary case-mix points.

Finally, CMS has decided to add case-mix and non-routine supply (NRS) status to the 173.XX (Other and unspecified malignant neoplasm of skin) retroactive to October 1, 2011.  The Medicare Administrative Contractors will issue direction regarding adjustment and resubmission of claims impacted by these codes.

Home health agency clinicians must be educated regarding these changes to ensure the accurate selection and proper sequencing of diagnoses codes.  One of the top reasons for home health Medicare claim rejection is the incorrect selection of diagnosis codes.

For more information go to the CMS website and download the 2013 Grouper documentation.

Until next time,


Up ↑

%d bloggers like this: