The CY 2022 home health final payment rule implements important changes in PDGM calculations. Among these changes is the expansion of the comorbidity groups. Nine (9) new subgroups were added to the Low Comorbidity category, while three (3) existing ones were removed, for a total of 20 subgroups. Furthermore, 56 new interactions were added (on top of 31 existing) to the High Comorbidity category for a total of 87 subgroup interactions starting 2022.
According to the Centers for Medicare & Medicaid Services (CMS), they have updated the comorbidity subgroups for CY 2022 based on home health data from CY 2020. In doing so, CMS utilized the same methodology used to establish the first set of comorbidity subgroups. To recall, in the CY 2019 Home Health Prospective Payment System (HH PPS) final rule, CMS stated that they will continue to examine the relationship of reported comorbidities on resource utilization and make the appropriate payment refinements to align with the actual costs of providing care.
Although the extent of the expansion is specified in the extensive final rule, there are not a lot of references emphasizing the updates in the comorbidity groups. Nevertheless, it is important for home health agencies to get on top of these new updates as they directly impact reimbursements. Coders and billing teams should be knowledgeable of these updates so they can be properly addressed in the documentation and claims processing as these new comorbidity groups present new opportunities to improve reimbursements.
Coding Secondary Diagnoses
Comorbidity adjustment is based on the secondary or other diagnoses that are found on the claim. The case-mix weight is increased by 6.01% with a Low Comorbidity adjustment and an additional 12.95% if a High Comorbidity adjustment applies.
To ensure all comorbidities are captured, coders need to thoroughly analyze all relevant patient medical records, such as history and physical (H&P) examination, discharge summaries, operative reports, and progress notes. Therefore, coders must be well accustomed to coding conventions and guidelines, medical terminologies, and disease processes.
The success of comorbidity coding lies largely on the specificity of diagnoses in patient records. Often, comorbidities are not clearly outlined in the documentation received from the referral source. In some cases, only symptom codes or ‘R Codes’ (which are symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified) are indicated in the documentation; these are not allowed to be assigned as secondary diagnoses.
Positioning of codes can change a claim’s clinical grouping and can trigger adjustments in the reimbursement level. Diagnosis sequencing (knowing which are primary and secondary) can be complex. Diagnosis identified as the primary reason for home health and documented by the physician on the face-to-face encounter could actually be in the first secondary diagnosis, rather than the primary due to such rules as manifestation, etiology codes, or “code first” coding instructions. The primary service and highest frequency of discipline must be taken into account when assigning a primary diagnosis. Considering all of these factors, there can be variations in the diagnoses sequencing.
Coding and Intake Collaboration
The first step to successful coding is the availability of complete and specific documentation. This underscores the importance of a strong collaboration between intake and coding.
The intake team needs to make sure that the referral documentation contains complete and specific information about the patient’s health condition especially on the specificity of the ICD codes.
Coders need to accurately assign a primary diagnosis that is consistent with the information from the referral order or face-to-face encounter. Additionally, they need to thoroughly analyze all relevant medical records to be able to assign the right comorbidity codes. Any unspecified diagnosis should be proactively queried from the referring physician with the help of the intake team.
Getting the Right Support
Staying on top of new updates can be overwhelming, especially ones that are technical and that affect reimbursements. The key is to establish a collaborative relationship between contributors in the agency, and have a strong support system that employs your needed expertise to execute the work with precision.
It is wise to have a partner with integrated clinical staffing solutions to reinforce and collaborate successfully with your in-house team. A good partner should not only be knowledgeable of important updates but should also know how to efficiently apply them into the workflow and leverage them to the agency’s advantage.
CY 2022 Home Health Final Rule >