|September 3, 2019
Home Health Changes in CMS Rules: Implications for Primary Diagnosis
The Home Health industry is looking toward significant changes on January 1, 2020 related to the Medicare reimbursement and payment. The industry will transition to a Patient Driven Grouper Model (PDGM) which will require a greater focus and importance on the Primary Diagnosis. The Primary Diagnosis will be a key factor in determining home health reimbursement as well as patient care and services.
Starting in 2020 this model of payment will not accept 40% of the Diagnoses that are currently being used as the Primary diagnosis. These are mainly symptom codes that do not give enough specificity as to the reason for the need for home health services. Studies show that 15% of current home health claims will not be in compliance in 2020 due to unacceptable Primary diagnoses, the number one Diagnosis used being Weakness M62.81.
Examples of these diagnoses that will not be accepted as the primary diagnosis include:
M62.81 Muscle Weakness
R26.89 Other abnormality of gait
R26.81 Unsteadiness of feet
R29.6 Repeated falls
R33.9 Retention of urine
M25.561/M25.562 Pain in right/left knee
M25.551/M25.552 Pain in right/left hip
M54.9 Dorsalgia, unspec.
M25.511/M25.512 Pain in right/left shoulder
M54.5 Low back pain
M19.90 Unspecified Osteoarthritis, unspecified site
M19.91 Primary Osteoarthritis, unspecified site
S72.001D Fracture of unspecified part of Rt femur
S72.002D Fracture of unspecified part of Left femur
In an effort to make sure all of our patients have Primary diagnoses that are acceptable to this new payment model by 2020, the Home Care & Hospice Alliance of Maine is sharing this information to alert Physicians and referral sources of this significant change. Please assist home care and hospice providers transition to this new model by starting now to make sure all patients needing home health will have a specific Diagnosis rather than one that only identifies a symptom.
The care of our patients is always our top priority and we hope the implementation of this new model will only help us improve the services that we provide.
Thank you for your referrals to home care and hospice.
Laurie Belden, Executive Director
Home Care & Hospice Alliance of Maine
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