PDGM Series 4/5: Trusting your Clinical Judgement

In our previous article, our goal was to simplify PDGM so you can easily understand the key components in the new payment model. For clinicians, it is important to know how you can provide value by learning about the changes and taking action. Most importantly, clinicians should continue to use their clinical judgement in assessing the patient and confirm it lines up with the documentation.

In this next article, we will dig in further to better understand how clinicians can use some of the guidelines which some EMRs (Electronic Medical Records) have begun to provide.

According to CMS.gov, PDGM uses “30-day periods as a basis for payment”. There are two subgroups period 1 and period 2 (or early and late periods) within the 60 day certification period.  CMS has determined that there are a total of 432 case-mix groups. How do we arrive at 432 case mixes? 

According to CMS.gov these are the broad categories to determine case mix:

  • Admission source (2x subgroups): community or institutional admission source
  • Timing of the 30-day period (2x subgroups): early or late
  • Clinical grouping (12x subgroups):
    • musculoskeletal rehabilitation;
    • neuro/stroke rehabilitation;
    • wounds;
    • behavioral health;
    • complex nursing interventions;
    • medication management, teaching, and assessment (MMTA)
      • 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
  • Functional impairment level (3x subgroups): low, medium, or high
  • Comorbidity adjustment (3x subgroups): none, low, or high based on secondary diagnoses. 

Using this formula:

     Admission source x Timing x Clinical Grouping x Functional Impairment x Comorbidity Adjustment

we get:

     2 x 2 x 12 x 3 x 3 = 432 possible case-mix adjusted payment groups.

The case mix is then represented in a Utilization guideline provided by an EMR. 

Here is an example of what a Utilization guideline might look like:

Let’s go over this.

Row 1: Timing

Timing can be expressed in 2 periods. Period 1 would be the first 30 days within the 60 day certification period. Period 2 can be the second 30 days within the 60 day certification period, in other words early vs late periods in the timing classification set by CMS.

Row 2: HIPPS or the Health Insurance Prospective Payment System.

These are codes based on the case mix formula in which distinct 5-position alphanumeric classifications are as follows:

Position 1 – Timing/Admission Source

Position 2 – Clinical Group

Position 3 – Functional Level

Position 4 – Comorbidity

Position 5 – Placeholder 

Row 3: Clinical Grouping

This refers to the primary diagnosis first listed on the claim. Depending on the primary diagnosis the clinical grouping will be one of these 12 categories. 

Row 4: LUPA (Low Utilization Payment Adjustment)

Under PDGM, the LUPA threshold can range from 2 to 6 visits and can vary across clinical groupings. There will be a different visit threshold for each of the new 432 home health resource groups (HHRGs).  Looking at this given number, it should be understood that LUPA threshold is not the same as the recommended visits.  As you plan your patients POC and plot the frequency and duration, take the LUPA threshold number into consideration. A LUPA adjustment occurs when the LUPA threshold is not met for the given 30 day payment period. If you believe that a LUPA threshold cannot be met, it is prudent to review the facts of the case and ensure there’s a valid reason that the case is an an outlier requiring a LUPA adjustment.

Row 5: Functional Impairment Level

This is determined by responses to the eight questions from the OASIS assessment. There are three levels assigned for reimbursement purposes – Low, Medium, and High functional impairment. 

Responses that indicate higher functional impairment and a higher risk of hospitalization are associated with higher resource use and are therefore assigned more points. These points are summed, and thresholds are applied to determine whether a 30-day period is assigned a low, medium, or high functional impairment level.

As mentioned in our last article, for a PT opening a case, checking the Functional Impairment score will help guide whether a patient is scored correctly. For anything scored other than high under the Functional Impairment section for a PT primary case, it is a good idea to double check the answers to the questions from the OASIS assessment. 

Row 6: Comorbility Adjustment

This is scored similarly to Functional Impairment level -None, Low, High, this is determined by secondary diagnoses based on reported claims. 

If this is scored Low, and you are aware the patient has comorbidities after taking their medical history, confirm those comorbidity diagnoses are coded. If not, verify them with the patient’s referring physician and notify your agency. 

In the above article we have described the elements of a utilization guideline and how this helps Agencies and Clinicians alike fulfill their responsibilities under the new guidelines set by PDGM. It is important to keep in mind that the frequency and intensity set must align with patient needs.  For therapists, this is determined by objective, measurable testing, and patient-centered goals for rehabilitation.

In our next article, we will summarize this series with some pointers from clinicians on the ground incorporating PDGM guidelines in their day to day.