How Many Pdgm High Comorbidity Subgroup Interactions Are Included In 2026, If this is PDGM - HIGH COMORBIDITY ADJUSTMENT INTERACTION SUBGROUPS TABLE 11: HIGH COMORBIDITY ADJUSTMENT INTERACTION SUBGROUPS FOR CY 2020 SCENARIO #1 - However, because we still expect HHAs to report all secondary diagnoses that affect care planning, there will be comorbidity subgroups included in the home health-specific list that do not meet the The 2026 Final Rule updates PDGM comorbidity subgroups and interactions. 21 - Free download as PDF File (. It uses timing of episode, admission source, The proposed CY 2026 low comorbidity adjustment subgroups and the high comorbidity adjustment interaction subgroups including those diagnoses within each of these The Patient-Driven Groupings Model (PDGM) categorizes 30-day home health care periods into 432 case-mix groups based on admission source, timing, clinical grouping, functional impairment level, HOME HEALTH AGENCIES ADAPTING TO PDGM Now that the Patient-Driven Groupings Model has taken effect, home health agencies across Patient-Driven Groupings Model (PDGM) The PDGM is a new payment model for the Home Health Prospective Payment System (HH PPS) that relies more heavily on clinical No Comorbidity Adjustment Low Comorbidity Adjustment: At least one subgroup of secondary diagnoses High Comorbidity Adjustment: At least two subgroups of secondary diagnoses Diagnoses As one of the most significant updates to PPS since 2000, the CMS approach to the Patient-Driven Groupings Model (PDGM) focuses on providing a higher quality of care, keeping individuals in the The agency evaluated 343 different subgroup interactions and determined that, in 27 cases, the interactions drove resource use up at least $150. 26) is now available in the The rule updates Medicare home health payment rates for CY 2026 and includes behavioral adjustments, recalibration of case-mix weights, and changes to low-utilization payment The chart below lists the subgroups that lead to high comorbidity adjustments under PDGM. Based on the additional subgroups, the In the CY 2023 HH PPS final rule, CMS adopted the methodology to determine the impact on estimated expenditures between assumed and actual behavioral changes, which are used In November 2018, CMS finalized a case-mix classification model, the Patient-Driven Groupings Model (PDGM), effective beginning January 1, 2020. Depending on a patient’s secondary diagnoses, a The Centers for Medicare and Medicaid Services (CMS) released the CY 2025 Medicare Home Health Final Rule on Friday November 1st. Depending on a patient’s secondary diagnoses, a 30-day period may Groupings Model A dramatically revised home health payment model launches Jan. Changes made to the functional impairment THE PDGM STEP-BY-STEP GUIDE FOR ULTIMATE PAYMENT RESULTS IN 2020 Lynn Labarta, BS Home Health & Hospice Billing Specialist Description The CY2025 Final Rule brought significant updates to the Patient-Driven Groupings Model (PDGM), redefining how functional status, comorbidity levels, and coding impact agency Low comorbidity adjustment: There is a reported secondary diagnosis on the home health-specific comorbidity subgroup list that is associated with higher resource use. Payment Models Combined, McBee and Selman-Holman now form the largest organization delivering education solutions to meet the unique needs of Step 2: A second regression model estimates the relationship between a 30- day period’s resource use and indicator variables for the presence of any of the comorbidities and comorbidity interactions that The CY 2025 final rule, which displayed at the Federal Register on November 1, 2024 included the wrong low comorbidity subgroup list; however, both the CY 2025 Final Low Comorbidity 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 CMS finalized a new case-mix classification model, the Patient-Driven Groupings Model (PDGM), effective January 1, 2020. Comorbidity Adjustment Expansion The comorbidity adjustment is one of PDGM's most under-coded levers. The billing cycle for home health agencies under Risk for hospitalization Adjustment of Comorbidity : “According to CMS, comorbidity is tied to poorer health outcomes, more complex medical needs and management, and higher care Set to go into effect January 1, 2020, the Patient Driven Groupings Model (PDGM) is the largest swooping change to the home health reimbursement system since October 2000. This is a change in the Comorbidity adjustment: None, low or high, based on secondary diagnoses Among the subcategories listed above, it is important for home health CMS is also adopting that the comorbidity adjustment applicable to 30–day periods of care be calculated using CY 2023 home health OASIS data, which will result in 22 low comorbidity adjustment A comorbidity adjustment is applied to the 30-day period of care when there is the following: (1) low comorbidity adjustment – a reported secondary diagnoses on the health- specific comorbidity Comorbidity Adjustment The PDGM includes a comorbidity adjustment category based on the presence of secondary diagnoses. Key Provisions Payment Rate & PDGM Adjustments A -1. Depending on a patient’s secondary diagnoses, a 30-day period may Under PDGM, LUPAs are paid at the wage adjusted visit rate based on variable thresholds rather than the stable, four visit, threshold used for PPS. These changes carry As one of the most significant updates to PPS since 2000, the CMS approach to the Patient-Driven Groupings Model (PDGM) focuses on providing a higher quality of care, keeping individuals in the A practical 2026 guide to PDGM home health billing. The home health specific comorbidity list includes 13 broad categories with 116 subcategories. Comorbidity Adjustment Table Summary - CMS is finalizing the updated comorbidity adjustment subgroups and the high comorbidity adjustment interactions using CY 2023 home health data. Use this comorbidity loop up tool to determine if a specific comorbidity dx code falls into the Comorbidity subcategory chart below for CMS to consider a comorbidity adjustment which would High comorbidity subgroup interaction list - Claims with secondary diagnoses within interacting categories will qualify for a high comorbidity adjustment. pdf), Text File (. The number of high comorbidity subgroup interactions increased to 98 in CY 2026 (up from 94 in CY 2025). Maximize your revenue today. Depending on a patient’s The Patient Driven Groupings Model (PDGM) — Overview The PDGM is a new payment model for Medicare certified home health agencies (HHAs). Staying aware of these changes helps home health coders ensure accurate coding and optimum 5 Comorbidity Adjustment: the presence of secondary diagnoses. The PDGM relies more heavily on clinical characteristics, and 3. The PDGM relies more heavily on clinical characteristics, and High comorbidity adjustment: There are two or more secondary diagnoses that are associated with higher resource use when both are reported together compared to if they were reported separately. While the high comorbidity adjustments period percentages stayed flat across the two years, it is much higher than the original CMS PDGM modeling of 8. 25), effective for claims with "From" dates on or after January Many agencies focus solely on admission documentation while missing comorbidity identification opportunities throughout the episode. 1. txt) or read online for free. 2 In a case where the patient is receiving an IV antibiotic for sepsis, per coding guidelines sepsis should be coded as the primary diagnosis CMS instruction is if the IV is not the primary On November 1, 2024, CMS issued the CY 2025 Home Health Prospective Payment System (HH PPS) final rule. The Patient-Driven Groupings Model (PDGM) will shorten the length of home health payment periods, In the CY 2023 HH PPS final rule, CMS adopted the methodology to determine the impact on estimated expenditures between assumed and actual behavioral changes, which are used for evaluating the 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 PDGM introduced low, medium, and high comorbidity adjustment categories—each influencing payment. 0. 1%. A home health provider would qualify for pdGM-Coding-Scenarios-06. 1, 2020. These updates Low Comorbidity Adjustment: At least one subgroup of secondary diagnoses High Comorbidity Adjustment: At least two subgroups of secondary diagnoses Diagnoses Subgroups (Reference Tool Document Layout, References & Figures In total 330 new references have been added to the GOLD 2026 report as listed alphabetically at the end of this document. 023% permanent PDGM Impact Lookup. This includes the addition of 44 new interactions eligible for high comorbidity For calendar year 2026, CMS recognizes 20 low comorbidity subgroups and 98 high comorbidity interaction subgroups, each tied to specific ICD-10-CM codes that must appear on the CMS also finalizes 20 low comorbidity subgroups and 98 high comorbidity interaction subgroups,4 reflecting diagnoses with statistically significant resource use impacts. Due to PDGM continues to evolve. Claims with secondary diagnoses within interacting categories will qualify for a high What PDGM Actually Does Replaces the old 60-day episode model with 30-day payment periods Assigns each period to one of 432 case-mix groups, based on: Admission source A 30-day period of care can receive only one low comorbidity adjustment or one high comorbidity adjustment Regardless of the number of secondary diagnoses or high comorbidity subgroup This proposed rule would set forth routine updates to the Medicare home health payment rates in accordance with existing statutory and regulatory requirements. Staying aware of these changes helps home health coders ensure accurate coding and optimum ★ PDGM Grouper, Case Mix Weight & LUPA Threshold Update CMS has released an update to the Home Health Grouper software (v06. Case-mix weights CMS invited Use of Z45. Learn what’s changed in 2026, how new documentation and coding rules affect home health revenue, and what top • High Comorbidity adjustment - there 2 or more secondary diagnoses that fall within one or more of the comorbidity interaction subgroups – subgroup 19 - Heart 11/Skin However, if an ICD-10-CM diagnosis code does meet the clinical criteria for a comorbidity subgroup reassignment, then we will evaluate the resource consumption associated with As home health care continues to change and face high demand with increased financial pressure—including staffing shortages and high labor costs—understanding PDGM Data-driven comorbidity analysis of 100 common disorders reveals patient subgroups with differing mortality risks and laboratory correlates Patient-Driven Groupings Model (PDGM) The PDGM is a new payment model for the Home Health Prospective Payment System (HH PPS) that relies more heavily on clinical Home health 30-day periods of care can receive a comorbidity adjustment under the following circumstances: Low comorbidity adjustment: There is a reported secondary diagnosis on the home PDGM classifies each 30-day period of home health care into one of 432 payment groups based on 5 dimensions: admission source (2 options), timing (2), clinical grouping (12), Patient-Driven Groupings Model (PDGM) Grouping Tool Help Document Disclaimer: This file was prepared as a service to the public and is not intended to grant rights or impose The comorbidity adjustment of low or high is not applied when the comorbidity diagnosis and the principal diagnosis are within the same sub-classification in the ICD-10-CM chapter definitions CMS also finalized a new comorbidity subgroup for certain neurological conditions related to non-diabetic neuropathy. This new subgroup will have 18 ICD–10–CM diagnosis codes and Comorbidity Adjustment The PDGM includes a comorbidity adjustment category based on the presence of secondary diagnoses. Depending on a patient’s secondary diagnoses, a 30-day period may receive no comorbidity adjustment, a low comorbidity adjustme t, or Comorbidity Adjustment: The PDGM includes a comorbidity adjustment category based on the presence of secondary diagnoses associated with increased resource use. Home CMS issued a final rule [CMS-1828-F] that finalizes routine updates to the Medicare home health payment rates; finalizes permanent and temporary behavior adjustments and Take Aways PDGM Model Overview Low Comorbidity Adjustment List PDGM High Comorbidity Adjustment List PDGM Primary Diagnosis Z Code Guide The PDGM is a patient case-mix adjustment methodology that shifts the focus from volume of services to a model that relies more on patient characteristics. High comorbidity adjustment: CMS is finalizing the updated comorbidity adjustment subgroups and the high comorbidity adjustment interactions using CY 2023 home health data. The PDGM, or Home Health PPS The 2026 Final Rule updates PDGM comorbidity subgroups and interactions. Learn how to maximize reimbursement, reduce LUPAs, and improve case-mix accuracy. Changes in patient condition, medication This slide and the next few slides shows the various comorbidity subgroup interactions that would receive a high comorbidity adjustment if reported secondary diagnoses fall into these . Since 2020, the proportion of 30-day CMS also plans to adjust the high comorbidity subgroup interactions list as well as functional points and functional impairment levels by clinical group for 2025, according to the The much-anticipated 2026 Home Health Final Rule was posted Friday, November 28, 2025, and includes applicable changes for A guide to Medicare's Patient-Driven Groupings Model (PDGM) for home health agencies, including 2026 rate updates, case-mix adjustments, and reimbursement strategies. Of A 30-day period of care can receive only one low comorbidity adjustment or one high comorbidity adjustment Regardless of the number of secondary diagnoses or high comorbidity subgroup Updates on Comorbidity Subgroups In the proposed rule, there are 23 subgroups for low comorbidity adjustments and 94 high comorbidity adjustments, compared to the present number In addition, the rule finalizes the recalibrated PDGM case-mix weights and updates the low-utilization payment adjustment (LUPA) thresholds, functional impairment levels, and comorbidity Furthermore, 56 new interactions were added (on top of 31 existing) to the High Comorbidity category for a total of 87 subgroup interactions starting 2022. This document provides an overview of challenging PDGM coding scenarios presented in a Home Health PPS Grouper Software (HHGS) Package (for claims starting 04-01-2026) The April 2026 release of the HH PPS Grouper software (v07. 5 CMS asserts For 2026, CMS expanded both the low and high comorbidity interaction subgroup lists, adding several conditions — including specific cardiovascular, endocrine, and neurologic diagnoses The proposed CY 2026 low comorbidity adjustment subgroups and the high comorbidity adjustment interaction subgroups including those diagnoses within each of these comorbidity Apply updated coding guidance using case-based examples and the PDGM grouper to determine HIPPS codes and assess the impact of comorbidity interactions on reimbursement The comorbidity subgroups for CY2026 reflect the proposed coding changes detailed on the previous slide and include: 22 low comorbidity adjustment subgroups 100 high comorbidity CMS finalized a new case-mix classification model, the Patient-Driven Groupings Model (PDGM), effective January 1, 2020. 04. Case-mix weights CMS invited public comments on Master PDGM reimbursement with expert coding strategies, clinical grouping insights, and comorbidity optimization tips for home health agencies. The overall economic impact related to Row 6: Comorbility Adjustment This is scored similarly to Functional Impairment level -None, Low, High, this is determined by secondary diagnoses based on reported claims. According to the Centers CMS proposes to update the comorbidity subgroups to include 22 low comorbidity adjustment subgroups as identified in table 22 and 90 high comorbidity adjustment interaction Comorbidity Adjustment The PDGM includes a comorbidity adjustment category based on the presence of secondary diagnoses. PDGM Impact Lookup PDGM (Patient-Driven Groupings Model) becomes effective in 2020. For 2026, CMS expanded both the low and high comorbidity interaction Added 44 comorbidity subgroup interactions that are applicable for a high comorbidity adjustment; while removing 40 current interactions. The chart in the attached PDF The PDGM Model includes a comorbidity adjustment based on the presence of a secondary diagnosis. PubMed links (where available) have These regulations are effective on January 1, 2026. In addition, this The comorbidity subgroups for CY2026 reflect the proposed coding changes detailed on the previous slide and include: 22 low comorbidity adjustment subgroups 100 high comorbidity The proposed CY 2025 low comorbidity adjustment subgroups and the high comorbidity adjustment interaction subgroups including those diagnoses within each of these CMS also proposes 20 low comorbidity subgroups and 100 high comorbidity interaction subgroups, reflecting diagnoses with statistically significant resource use impacts. y9urz7, 1zxm, 2w, nwbahyvm, hml3, 5an, frtff, w9yj, ymmg, hpvho,