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License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

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CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

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The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
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CGS Overview: Home Health Patient-Driven Groupings Model (PDGM)

Effective for claims with a “From” date on or after January 1, 2020, Change Request (CR) 11081 implements the policies of the home health Patient-Driven Groupings Model (PDGM) as described in the Calendar Year (CY) 2020 home health (HH) final rule (CMS-1711-FCExternal PDF). The PDGM changes the unit of payment from 60-day episodes of care to 30-day periods of care and eliminates the therapy thresholds used in determining home health payment.

Implementation
For 60-day episodes that begin on or before December 31, 2019, and span January 1, 2020, the payment will be the calendar year (CY) national, standardized 60-day episode payment amount.

For HH periods of care that begin on or after January 1, 2020, the unit of payment will be the CY 2020 national, standardized 30-day payment amount.

Under PDGM, recertification for home health services, updates to the comprehensive assessment and updates to the HH plan of care continue on a 60-day basis.

Resources:

This page includes the following information (click the title to access):

Home Health Prospective Payment System (HH PPS) vs PDGM

Claim Filing Elements

The following claims filing elements are new under the PDGM. 

Occurrence Code (OC)

NOTE: If OC 61 and 62 are not present, Medicare systems will use inpatient claims history to assign Institutional payment groups based on the most current information.

Treatment Authorization Code
The treatment authorization code, which is reported under HH PPS in the TREAT. AUTH.CODE field on the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE), Claim Page 05, is no longer required. This field will only be used when required by the pre-claim review process when it actually represents an authorization number.

Principal and Other Diagnosis Code
The principle and other diagnosis ICD codes on the claim will be used for payment grouping rather than the OASIS item. As a result, the claim and OASIS diagnosis codes will no longer be expected to match in all cases. When diagnosis codes change between one 30-day claim and the next, HHAs are not required to complete an ‘other follow-up’ (RFA 05) assessment.  However, an ‘other follow-up’ (RFA 05) assessment is required when such a change would be considered a major decline or improvement in the patient’s hearth status.  Refer to the MM11272External PDF for additional information.

Health Insurance Prospective Payment System (HIPPS) Code

After January 1, 2020, under the Patient-Driven Payment Model, a case-mix adjusted payment for a 30 day period of care is made using one of 432 home health resources groups (HHRGS).  On Medicare claims, the HHRGs are represented as Health Insurance Prospective Payment System (HIPPS) Codes. The distinct 5-position, alphanumeric home health HIPPS codes are created as follows:

  • First Position - a numeric value representing a combination of the referral source (community or institutional) and the period timing (early or late).
  • Second and Third Positions - represent the clinical and functional domains of the HHRG coding system.
  • Fourth Position - represents the co-morbidity category that applies to the patient.
  • Fifth Position - a placeholder for future use, required only because the field used to report HIPPS codes requires five positions.

Using this structure, a second period for a patient with a hospital inpatient stay during the period (institutional late), in the Wounds group, high functional severity and no co-morbidity would be coded 4CC11. HIPPS codes continue to be reported with revenue code 0023.

Low Utilization Payment Adjustment (LUPA)

For periods of care beginning on or after January 1, 2020, if an HHA provides fewer than the threshold of visits specified for the period’s HHRG, they will be paid a standardized per visit payment instead of a payment for a 30-day period of care.  Under PDGM each of the 432 case-mix groups has a threshold to determine if the period of care would receive a LUPA. This threshold is determined by the 10th percentile of visits in each payment group with a minimum threshold of 2

Partial Payment Adjustment

A partial payment adjustment will apply if a beneficiary transfers from one HHA to another, or is discharged and readmitted to the same HHA within 30 days of the original 30-day period start date.  The adjustment is pro-rated based on the length of the 30-day period ending in transfer or discharge and readmission, resulting in a partial period of payment.

Outlier Payment

When cases “lie outside” expected home care experience by involving an unusually high level of services in 60-day episodes under HH PPS, or 30-day periods of care under PDGM, Medicare claims processing systems will provide extra or “outlier” payment. Outlier payments can result from medically necessary high utilization in any or all of the service disciplines.

Posted: 11.25.19

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