Heads Up to FPs: Medicare Home Health Changes Coming Jan. 1

December 10, 2019 12:34 pm News Staff

Family physicians who order home health services for their patients should be aware of upcoming changes to Medicare payment for those services. Specifically, on Jan. 1, 2020, the home health unit of payment will change from the current 60 days to 30 days, an adjustment intended to ensure that patients' care needs are being actively monitored and met.

[home health visit]

These changes won't directly impact physicians' payment, according to a Dec. 4 post in FPM's Getting Paid Blog titled "New Medicare home health payment feature has implications for physician orders."

But physicians would do well to stay engaged.

According to blog author Kent More, the AAFP's senior strategist for physician payment, the new payment methodology may affect how physicians order home health services for their Medicare patients.

Moore explains that under the Patient-Driven Groupings Model, "the principal diagnosis code on the home health claim will assign the home health period of care to a clinical group that explains the primary reason the patient is receiving home health services."

He adds that some diagnoses are "vague, unspecified or not allowed to be reported as a principal diagnosis by ICD-10 coding guidelines that will not be assigned into a clinical group."

It's likely that such claims will be returned to the home health agency supplying the services; in turn, the agency will contact the ordering physician for more definitive diagnosis coding.

"Use the most specific diagnosis you can when ordering home health for your Medicare patients," advises Moore, who gives some specific examples in his blog.

For its part, CMS recently provided guidance in two special editions of its Medicare Learning Network publication MLN Matters.

In a Nov. 22 article(www.cms.gov) titled "Overview of the Patient-Driven Groupings Model," CMS reminds physicians that with implementation of the new Home Health Prospective Payment System case-mix adjustment methodology comes a high level of need for accurate diagnosis reporting and physician documentation.

"Under the Medicare home health benefit, the patient must be under the care of a physician and must be receiving home health services under a plan of care established and periodically reviewed by a physician," says the article.

It notes that with the change to a 30-day unit of payment, home health agencies "may have more frequent contact with the certifying physician to communicate any changes in the patient's condition to ensure that home health payment is adjusted to account for those changes."

Importantly, home health services are not limited to a single 30-day period of care. "An individual can continue to receive home health services for subsequent 30-day periods as long as the individual continues to meet home health eligibility criteria," says the article.

CMS notes that aside from implementation of the 30-day unit of payment, no changes have been made to existing timelines to recertify eligibility and review the home health plan of care. Both of these actions "still need to occur every 60 days," or, if the care plan is updated, more often as the patient's condition calls for.

The same article also provides details about

  • home health service eligibility requirements,
  • essential criteria for a homebound designation and
  • the five categories included in the Patient-Driven Groupings Model.

A second MLN Matters article(www.cms.gov) provides additional information on implementation of the PDGM, including the case-mix variables representing the clinical characteristics that affect resource use.