CMS Issues Manual Updates for PDGM

WASHINGTON, D.C. (November 20, 2019)—The Centers for Medicare and Medicaid Services (CMS) has issued Change Request (CR) 11527, which includes further updates to the Claims Processing Manual, chapter 10, related to the Patient Driven Groupings Model (PDGM).

The CR clarifies that a beneficiary is not required to be discharged form home health services if an inpatient stay spans across two 30-day periods within a certification period. The 30-day periods are contiguous, even if the patient returns to the agency after the beginning of the next 30-day period. The agency should submit the request for anticipated payment (RAP) and the claim with the “from” date as Day 31 of the next period and the first visit date after discharge from the facility. For example, if the patient is admitted to an inpatient facility on Day 28 of the first 30 day period and the agency resumes care on Day 35 (or Day Five of the next 30-day period) the “from” date on the RAP and claim will be the date that reflects Day 31 and the first visit date will reflect the date for Day five of the next 30-day period. The home health claim will process as long as there no dates of service on the claim that overlap the dates of service for the inpatient stay.

The CR also establishes a process to address 30-day periods where there are no visits because the POC requires visits less frequently than every 30 days.

For instance, if the beneficiary’s plan of care requires that the beneficiary is seen every six weeks and there is a recertification, the beneficiary might receive no visits in the first 30-day period following the recertification. In this case, the HHA should submit a RAP for all 30-day periods, but only submit claims for 30-day periods in which visits were delivered.

If no visits are expected during an upcoming 30-day period, the HHA should submit the RAP with the first day of the period of care as the service date on the 0023 line. The RAP for a period with no visit will ensure the HHA remains recorded on Medicare’s Common Working File (CWF) system as the primary HHA for the beneficiary and will ensure that HH consolidated billing is enforced. If no visits are provided, the RAP will later be autocancelled to recover the payment.

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