Coders can expect to confront new challenges, including new payment models and HIPAA changes.
The new year brings new challenges for the healthcare industry. From new payment models to updates to the Health Insurance Portability and Accountability Act (HIPAA) to 21st Century Cures, hold on to your hats, because it is going to be a bumpy ride!
The Patient Driven Groupings Model (PDGM) will be implemented by the Centers for Medicare & Medicaid Services (CMS) on Oct. 1, 2019 for Skilled Nursing Facility (SNF) patients. The Health Insurance Prospective Payment System (HIPPS) code will still be reported, but the new system will not be based on Resource Utilization Group version IV. The principal diagnosis will determine the patient’s clinical category. The new groups are based on:
- Physical therapy (clinical category and functional score);
- Occupational therapy (clinical category and functional score);
- Speech and language (presence of acute neurological condition, SLP comorbidity or cognitive impairment, mechanically altered diet, and swallowing disorder);
- Non-therapy ancillary (comorbidities based on ICD-10-CM secondary diagnoses); and
- Nursing (same as RUG-IV).
There is also a variable per diem adjustment that changes the rate over the course of the patient’s stay. The Minimum Data Set (MDS) will continue to be used under the new methodology as well.
The Patient Driven Groupings Model (PDGM) will be implemented by CMS on Jan. 1, 2020 for home health patients. There are 432 possible case-mix adjusted payment groups for each 30-day period. The groups are based on:
- Timing (initial or subsequent);
- Admission source (community or institutional);
- Clinical grouping (based on principal diagnosis);
- Functional impairment (using specific OASIS items);
- Comorbidity adjustment (secondary diagnoses); and
- Additional payment adjustments based on cost and frequency of visits.
These two reimbursement methodologies will utilize ICD-10-CM diagnosis codes more than the previous methodologies.
Program Note:
Listen to Laurie Johnson report these changes today on Talk Ten Tuesday at 10 a.m. Eastern.
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Resources:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM-101_Final.pdf
https://www.himss.org/event/himss-quarterly-winter-interoperability-hie-community-roundtable
http://cqrcengage.com/ahima/app/document/28265335
