Pdgm Comorbidity Adjustment Table, Prepare for a possible 45-day QRP submission window.

Pdgm Comorbidity Adjustment Table, No secondary diagnoses exist, or none meet the criteria for a low or high comorbidity adjustment. HIGH comorbidity adjustment interaction subgroups The chart below lists the subgroups tha. E. . We also updat the CY 2026 national, standardized 30-day period payment rates and the CY 2026 national per- visit payment amounts by the home health payment update percentage. Comorbidity Adjustment Low comorbidity adjustment: There is a reported secondary diagnosis that falls within one of the home-health specific individual comorbidity subgroups associated with higher resource use, or; 5. The comorbidity adjustment has three levels: The case mix weight is increased by 6. Timing of the 30-day period (two subgroups): early or late. impairment levels, and comorbidity adjustment subgroups. 08% increase in case-mix from No to Low 5 Comorbidity Adjustment: the presence of secondary diagnoses. Nov 13, 2023 · Under this case-mix methodology, case-mix weights are generated for each of the different PDGM payment groups by regressing resource use for each of the five categories (admission source, timing, clinical grouping, functional impairment level, and comorbidity adjustment) using a fixed effects model. The comorbidity adjustment in PDGM can increase pa. The changes are intended to more accurately capture real-world resource utilization patterns for patients with multiple conditions. Clinical grouping (twelve subgroups): musculoskeletal rehabilitation; neuro/strokerehabilitation; wounds; Medication Management, Teaching, and Assessment (MMTA) Functional impairment level (three subgroups): low, medium, or high. Payments adjust based on patient's secondary diagnoses as reported by the HHA on the home health claim. Jul 30, 2024 · Up to 25 diagnoses will fit in the electronic claims file. The final home health PDGM: Comorbidity Adjustment Cheat Sheet This cheat sheet explains the process, provides useful tips, and details which diagnoses codes apply to the designed comorbidity groups and where they fall into the low and high categories. 95% if a High Comorbidity adjustment applies. Claims with secondary diagnoses within interacting categori. Depending on a patient’s secondary diagnoses, a 30-day period may receive no comorbidity adjustment, a low comorbidity adjustment, or a high comorbidity adjustment. Shorten your reporting cycle. Build a rate forecast factoring in a -6. The proposed CY 2026 low comorbidity adjustment subgroups and the high comorbidity adjustment interaction subgroups including those diagnoses within each of these comorbidity adjustments are shown in tables 22 and 23 on pages 63-71 of the rule. Review functional scoring and comorbidity logic before recalibration goes live. Nov 30, 2025 · While a table of contents has been provided, page numbers are added. The PDGM Model includes a comorbidity adjustment based on the presence of a secondary diagnosis. Nov 7, 2024 · In addition, this rule finalizes the recalibrated PDGM case-mix weights and updates the low-utilization payment adjustment (LUPA) thresholds, functional impairment levels, and ( printed page 88355) comorbidity adjustment subgroups under section 1895 (b) (4) (A) (i) and (b) (4) (B) of the Act for 30-day periods of care in CY 2025; finalizes the Jul 1, 2025 · Under the PDGM, patients are classified into one of 432 case-mix groups based on clinical condition, admission source, episode timing, functional impairment level, and comorbidity adjustment. Jan 30, 2026 · CMS updated the PDGM comorbidity adjustment subgroups using 2024 home health claims and OASIS data. Tighten NOA workflows. The home health specific comorbidity list includes 13 broad categories with 116 subcategories. Prepare for a possible 45-day QRP submission window. Admission source (two subgroups): community or institutional admission source. Uses the presence of home health specific comorbidities as part of the overall case-mix adjustment. The following table identifies the Economic Costs And Transfers. Late NOAs remain the most preventable cause of payment loss. Learn more about the comorbidity adjustment category of the PDGM and how it applies to your home health agency. Comorbidity Adjustment Principal Diagnosis Determines the PDGM Clinical Grouping Secondary Diagnosis Impacts Case Mix Adjustments A Comorbidity is defined as a medical condition coexisting in addition to a principal diagnosis Dec 19, 2025 · Comorbidity Adjustment Table Summary - This table provides a break out of the agencies billing periods into the three comorbidity categories, none, low, and high. The rule does provide helpful final decision sections. Depending on a patient’s secondary diagnoses, a 30-day period may receive no comorbidity adjustment, a low comorbidity adjustme t, or a high comorbidity adjustment. 01% with a Low Comorbidity adjustment and an additional 12. lead to high comorbidity adjustments under PDGM. 4% overall adjustment. Refresh PDGM knowledge. Jul 2, 2025 · In addition, this rule proposes to recalibrate the PDGM case-mix weights and to update the low-utilization payment adjustment (LUPA) thresholds, functional impairment levels, and comorbidity adjustment subgroups under sections 1895 (b) (4) (A) (i) and (b) (4) (B) of the Act for 30-day periods of care in CY 2026. of this final rul , we update the home health wage index. 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