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CMS Adds Correction to PDGM Billing Instructions

Wednesday, May 29, 2019   (0 Comments)

Courtesy of the National Association for Home Care & Hospice

Earlier this month, the The Centers for Medicare & Medicaid Services (CMS) released a second set of revisions to Chapter 10 of the Medicare Claims Processing Manual providing instructions to home health agencies for claims submission under the Patient-Driven Groupings Model (PDGM) — CMS Transmittal 4294/Change Request (CR) 11272, Home Health (HH) Patient-Driven Groupings Model (PDGM) – Additional Manual Instructions.

During a recent CMS Home Health, Hospice, & DME Open Door Forum (ODF), CMS indicated it would be correcting the CR to reflect the new diagnosis instructions that were added to section 40.2 (HH claims) of the Claims Processing Manual, Chapter 10 – Home Health Agency Billing, would be added to section 40.1 (RAPs) as they are applicable to both sections. Click here to view the corrected CR.

Specifically, under PDGM ICD-10 codes used for payment groupings will be taken from claim instead of the OASIS. As a result, the claims and OASIS diagnosis codes will not be expected to match in all cases. Second 30-day claims in any 60 day period will not necessarily match the OASIS assessment. When diagnosis codes change between one 30-day claim and the next, there is no requirement for agencies to complete an OASIS Other Follow-up Assessment (RFA05) just to ensure that the diagnosis codes match the assessment.  However, the agency is required to complete the RFA05 when there is a change due to major decline or improvement in the health status of the patient.

To reiterate, this change was not reflected in the RAP section of the Manual and is now corrected.


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