Diagnoses not allowed under PDGM

Most R codes are still out, but newest version of CMS Grouper Tool allows a few

When home care providers learned that the Centers for Medicare and Medicaid Services (CMS) would no longer allow some common home health diagnoses to be primary under the new payment model taking effect next year, there was plenty of industry pushback.

Low back pain, repeated falls, weakness, abnormalities in gait and other symptoms are common reasons physicians refer home health services for elderly patients, agencies told CMS during the comment period for the proposed Patient-Driven Grouping Model (PDGM) -- and the underlying medical reason causing these symptoms isn't always determined.

Sometimes physicians are still in the process of diagnosing the reason for the symptoms, agencies said. Other times elderly patients and their physicians decline to pursue further diagnostic testing because it can be expensive, time-consuming and -- since these patients are homebound, problematic as far as getting to and from necessary appointments. But CMS is standing by most of its earlier decision against R codes, saying in the finalized version of PDGM that agencies must refrain from using symptom codes as the primary diagnosis for the home health episode, with only a limited number of specific exceptions. The final version of PDGM was released Oct. 31 as part of the CY 2020 Final Rule. "CMS says the reason for its stance on the use of symptom codes is that the underlying condition will dictate the treatment," said J'non Griffin, Home Health Solutions President and Owner. "In the case of gait abnormalities, for example, a patient whose gait abnormalities are due to neurological issues would be expected to have a completely different care plan from a patient whose gait abnormalities are due to fractures or some type of traumatic injury," J'non said. CMS says agencies must know the cause of the gait abnormalities in order to provide services which meet health and safety needs for that patient, and are reasonable and necessary by industry standards for that particular injury, illness or medical condition. As for cases in which no reason for the symptom has been determined, CMS isn't buying it. "We believe that by the time an individual is admitted to home health, the patient has been seen by other health care providers and a diagnosis has been established,” CMS stated in the Final Rule.

Dysphagia is an exception

One exception to the prohibited use of symptom codes as primary under PDGM is dysphagia, a medical condition in which patients experience difficulty swallowing. The CMS Grouper Tool which agencies must use in order to determine the clinical grouping for a primary diagnosis under PDGM has been modified to accept dysphagia as a primary diagnosis. CMS released a new, finalized version of its Grouper Tool along with the Final Rule. The new version assigns these R codes for dysphagia to the Neuro Rehab clinical group:

  • R13.10, Dysphagia, unspecified

  • R13.11, Dysphagia, oral phase

  • R13.12, Dysphagia, oropharyngeal phase

  • R13.13 Dysphagia, pharyngeal phase

  • R13.14, Dysphagia, pharyngoesophageal phase

  • R13.19, Other dysphagia Although the CMS Grouper Tool places dysphagia into the Neuro Rehab grouping, dysphagia can have other causes which are not neurological in origin. "While we understand that dysphagia could be the result of non-neurological conditions, we are assigning these dysphagia groups to the Neuro Rehab group as we believe the intensity of speech-language pathology therapy would be similar to those suffering from dysphagia resulting from a neurological condition," CMS states in the Final Rule "However, we will monitor the use of these dysphagia R codes to determine their impact on resources utilization and whether any future changes would be warranted.”

Primary diagnoses not allowed

Among the symptom codes specifically requested by agencies but nixed by CMS for clinical grouping assignment as a primary diagnosis are:

  • R26.89, Other abnormalities of gait and mobility

  • R29.6, Repeated falls

  • R00.1, Bradycardia

  • R41.82, Altered Mental Status

  • R42, Dizziness and giddiness

  • R27.0, Ataxia, unspecified

  • M62.81, Muscle weakness, generalized

  • M62.838, Other muscle spasm

In rejecting M62.81, as one example, CMS describes it as "a vague code that does not clearly support a rationale for skilled services" and "does not support a comprehensive plan of care" in line with accepted professional standards of clinical practice. The explanation provided by CMS for its decision not to allow M62.81 as a primary diagnosis under PDGM offers insight into the reasoning behind its overall rejection of symptom codes as primary diagnoses, according to J'non. "CMS is requiring agencies to be more specific, and to go back and query the MD if necessary to deterine what is really going on with this patient in order to develop an effective and patient-specific plan of care," she said.

"If there is not an identified cause of muscle weakness, CMS is saying it would be questionable as to whether the course of therapy treatment would be in accordance with accepted professional standards of clinical practice." Diagnoses moved

Among other changes made to the finalized Grouper Tool, CMS moved many I87 venous insufficiency and venous hypertension ulcer codes from the MMTA-Cardiac clinical grouping to Wounds. "Numerous changes were made. Be sure and delete older versions of the CMS Grouper Tool and make certain to use the newest, finalized version, as these changes will make a big difference," J'non cautions agencies.

Get the word out to physicians

One of the challenges ahead for agencies as the PDGM implementation date nears is to make certain physicians are on board with the required changes in identifying the underlying medical condition for all patients.

Home Health Solutions offers a "Tools for Tough Talk" package in our online store designed to help home health agencies have though important discussions with referral sources. Our printable brochure can be customized with agency information, printed out, folded and taken to meetings with physicians to discuss PDGM changes. The package is sold for $19.99 in The Solutions Shop.