March 29, 2022 | Net Health

2 min read

CMS Hosts PDGM National Provider Call

On Wednesday, August 21, CMS hosted a National Provider Call for home health providers titled “Home Health Patient-Driven Groupings Model: Operational Issues.” The presentation discussed PDGM claims submission, new occurrence codes, and several scenarios related to early vs. late timing of 30-day periods and institutional vs. community admissions.

Highlights include:

  • Three new occurrence codes for PDGM: 50, 61, 62
    • Occurrence code 50 – Occurrence code 50 indicated that “Assessment Date” is required on all final HH claims under PDGM. Occurrence code 50 reports the assessment completion date (M0090). A mismatch between occurrence code 50 and M0090 will result in the claim being returned.
    • Occurrence code 61 – “Hospital Discharge Date” is reported, but not required, on final admission claims and continuing claims, if applicable. This code reports the discharge date (“Through” date) of an inpatient hospital admission that ended within 14 days of the “From” date of the HH period of care and classifies the 30-day period as Institutional.
    • Occurrence code 62 – “Other Institutional Discharge Date” is reported, but not required, on admission claims only, if applicable. This code reports discharge from a SNF, LTCH, IRF, or IPF within 14 days of the “From” date of the HH period of care. The claim “From” date and “Admission” date must match in order for the period to be classified as Institutional.
  • Medicare Secondary Payer (MSP) home health periods ARE counted when determining early/late, whereas Medicare Advantage (MA) period ARE NOT
  • Implementation date for PDGM in Medicare instructions is January 6, 2020 – RAPs and claims with “From” dates after January 1, 2020 will be held by the MAC and then released for processing after January 6 to prevent them from being returned in error
  • Non-Medicare inpatient stays will only be able to be indicated via occurrence codes 61 of 62 on the claim, as CMS has no way to validate this information in their claims system

To learn about Occurrence code 50, 61 and 62 and to access the presentation call details, click here.

For more information on these PDGM changes, read CMS Hosts PDGM National Provider Call On Claims Submission & Processing.

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