CMS Hosts PDGM National Provider Call

CMS Hosts PDGM National Provider Call

On Wednesday, August 21, CMS hosted a National Provider Call for home health providers titled “Home Health Patient-Driven Groupings Model: Operational Issues.” The presentation discussed PDGM claims submission, new occurrence codes, and several scenarios related to early vs. late timing of 30-day periods and institutional vs. community admissions.

Highlights include:

  • Three new occurrence codes for PDGM: 50, 61, 62
    • Occurrence code 50 – “Assessment Date” is required on all final HH claims under PDGM. This code reports the assessment completion date (M0090). A mismatch between occurrence code 50 and M0090 will result in the claim being returned.
    • Occurrence code 61 – “Hospital Discharge Date” is reported, but not required, on final admission claims and continuing claims, if applicable. This code reports the discharge date (“Through” date) of an inpatient hospital admission that ended within 14 days of the “From” date of the HH period of care and classifies the 30-day period as Institutional.
    • Occurrence code 62 – “Other Institutional Discharge Date” is reported, but not required, on admission claims only, if applicable. This code reports discharge from a SNF, LTCH, IRF, or IPF within 14 days of the “From” date of the HH period of care. The claim “From” date and “Admission” date must match in order for the period to be classified as Institutional.
  • Medicare Secondary Payer (MSP) home health periods ARE counted when determining early/late, whereas Medicare Advantage (MA) period ARE NOT
  • Implementation date for PDGM in Medicare instructions is January 6, 2020 – RAPs and claims with “From” dates after January 1, 2020 will be held by the MAC and then released for processing after January 6 to prevent them from being returned in error
  • Non-Medicare inpatient stays will only be able to be indicated via occurrence codes 61 of 62 on the claim, as CMS has no way to validate this information in their claims system

To access the presentation and the call details, click here.

For more information, read CMS Hosts PDGM National Provider Call On Claims Submission & Processing.

Holly Hester

Holly Hester is Casamba’s Senior Vice President of Compliance & Education, as well as the Compliance Officer. She provides regulatory guidance and interpretation, clinical programming and content development, education and training steerage, and compliance support for the company. As a physical therapist for more than 20 years, Holly has multi-venue clinical and management experience, giving her a unique perspective on the integration of compliance and training with therapy service delivery and clinical practice.
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