PDGM grouper educational information & resources
The information below contains educational content & resources for each section of the PDGM grouper tool.
Number of Visits
The number of visits should include the actual planned in-home visits with the patient, including nursing, PT, OT, SLP, MSW and home health aide. Telehealth visits do not count as visits at this time. LUPAs or Low Utilization Payment Adjustments are paid by the visit rather than the 30 day billing period. LUPA thresholds are different (from 2 - 6 visits) based on the clinical grouper and other aspects of the HIPPS. LUPA rates for CY2021 are:
By placing the number of visits into the calculator, you can determine whether the payment will be based on a LUPA or a 30-day billing period.
Related resources & tools:
Source - Community vs. Institutional
Related resources & tools:
Comorbidity
- Low comorbidity adjustment: There is a reported secondary diagnosis on the home health-specific comorbidity subgroup list that is associated with higher resource use.
- High comorbidity adjustment: There are two or more secondary diagnoses on the home health-specific comorbidity subgroup interaction list that are associated with higher resource use when both are reported together compared to if they were reported separately. That is, the two diagnoses may interact with one another, resulting in higher resource use.
- No comorbidity adjustment: A 30-day period of care will receive no comorbidity adjustment if no secondary diagnoses exist or none meet the criteria for a low or high comorbidity adjustment. CMS estimates roughly 50% of claims will receive no comorbidity adjustment.
A 30-day period of care can receive only one low comorbidity adjustment regardless of the number of secondary diagnoses reported on the home health claim that fell into one of the individual comorbidity subgroups or one high comorbidity adjustment regardless of the number of comorbidity group interactions, as applicable. The low comorbidity adjustment amount will be the same across the subgroups and the high comorbidity adjustment will be the same across subgroup interactions.
Primary Diagnosis
The Wound Grouper is one of the highest paying groupers, however, you want to ensure that your documentation supports the use of the wound grouper. There are three aspects of wound care that are considered skilled:
- Direct care (actual wound care)
- Teaching and training
- Observation and assessment of a potentially fluctuating condition.
Related resources & tools:
Functional Score
The functional score is the only part of the HIPPS code that is derived from the response to the OASIS. Every other part of the HIPPS code is derived from the claims system or the claim.