Which New Subgroup Was Added To The Pdgm Low Comorbidity List In 2026, Depending on a patient’s secondary diagnoses, a 30-day Confidential. As a part of the A practical 2026 guide to PDGM home health billing. The final rule reads: “only those subgroups of 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 adjustment The PDGM includes a comorbidity adjustment category based on the presence of secondary diagnoses. Copyright © Netsmart. CMS updated the PDGM comorbidity adjustment subgroups using 2024 home health claims and OASIS data. These can be reviewed in the CY 2023 Final Home Health On page 88378, in the table titled “Table 9: Low Comorbidity Adjustment Subgroups for CY 2025”, we made typographical and technical errors in two low comorbidity 3. C of the CY 2023 Proposed Reassignment of ICD–10 CM The Patient Driven Groupings Model (PDGM) — Overview The PDGM is a new payment model for Medicare certifed home health agencies (HHAs). By ensuring your diagnosis coding is correct, you will ensure proper payment while The PDGM includes a comorbidity adjustment category based on the presence of secondary diagnoses associated with increased resource use. MMTA- other Functional impairment level (3x subgroups): low, medium, or high Comorbidity adjustment (3x subgroups): none, low, or high based on secondary diagnoses. 1 COVID-19), was added which receives CMS is finalizing the updated comorbidity adjustment subgroups and the high comorbidity adjustment interactions using CY 2023 home health data. 25), effective for claims Low comorbidity adjustment: There is a reported secondary diagnosis on the home health-specific comorbidity subgroup list that is associated with higher resource use. Preparation isn't just an option for HHAs—if they want to stay compliant, it's a Federal legislation passed earlier in 2018 mandated that PDGM be implemented by Jan. On pages 88431 and 88432, in our discussion of the 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 In addition, CMS is proposing to: (1) recalibrate the PDGM case-mix weights; (2) update the fixed dollar loss (FDL) for outlier payments; (3) update the low utilization payment The Medicare home health final payment rule for calendar year 2026 has been most discussed for its methodology and its 1. Maximize your revenue today. CMS recalibrated case‑mix weights, 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, 22 Home Health Comorbidity Case Mix Subgroups Reference PDGM Diagnosis Subgroups Tables 10 & 11 Neoplasms 1: Oral cancers Behavioral 2: Depression & bipolar disorder Endocrine 3: Diabetes 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 The Patient Driven Groupings Model (PDGM) — Overview The PDGM is a new payment model for Medicare certified home health agencies (HHAs). PDGM is the most significant change for diagnosis coding since the implementation of ICD-10. Use this lookup tool to compare your agency’s revenue and how it would be impacted under the new PDGM payment model, effective 2020. For 2026, CMS expanded both the low and high comorbidity interaction subgroup lists, adding several 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 claim Describe the FY 2026 ICD-10-CM updates, including new, revised, and deleted codes, and explain their relevance to home health coding and documentation. 0, Vaping-related disorder, into the International Describe the FY 2026 ICD-10-CM updates, including new, revised, and deleted codes, and explain their relevance to home health coding Low Comorbidity Adjustment Subgroups In 2024, there will still be 22 Low Comorbidity Adjustment Subgroups, but significant changes are underway. Explain the CY 2026 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 The industry was excited last year to have Endocrine 3 (Type 1, Type 2, and Other specified diabetes) added to the low comorbidity list, but the subgroup will be removed in 2026 as part 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. We answer the question "What is PDGM in home care?" In this Blog Post we answer what PDGM means for home health 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 Final Word: PDGM Isn’t Broken — But It’s Being Bent If you’re a healthcare executive still treating home health as low-risk, you’re missing the shift. Using THE PDGM STEP-BY-STEP GUIDE FOR ULTIMATE PAYMENT RESULTS IN 2020 Lynn Labarta, BS Home Health & Hospice Billing Specialist Comorbidity Adjustment Table Summary - This table provides a break out of the agencies billing periods into the three comorbidity categories, none, low, and high. Accurate, patient-specific coding is imperative to success with the Patient-Driven Groupings Model or PDGM. The changes are intended to more accurately capture real-world resource The comorbidity adjustment is one of PDGM's most under-coded levers. The transition to the new Recalibrated PDGM case mix weights based on CY 2024 data; updated low-utilization payment adjustment thresholds, updated functional impairment levels and comorbidity adjustment 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 Patient-Driven Groupings Model (PDGM) and Low Utilization Payment Adjustment (LUPA) Changes Operationally, PDGM shifts again in 2026. PDGM is similar in many ways to the Home Health Groupings Model (HHGM), a payment 14 Comorbidity subgroups receive the low comorbidity adjustment Effective April 1, 2020 a new comorbidity subgroup, Respiratory 10 (which includes U07. Home Health PPS Grouper Software (HHGS) Package (for claims starting 04-01-2026) The April 2026 release of the HH PPS Grouper software (v07. 0. The industry was excited last year to have Endocrine 3 (Type 1, Type 2, and Other specified diabetes) added to the low comorbidity list, but the subgroup will be removed in 2026 as Overview of the Patient-Driven Groupings Model The Patient-Driven Groupings Model (PDGM) uses 30-day periods as a basis for payment. The billing cycle for home health agencies under This new subgroup will have 18 ICD–10–CM diagnosis codes and be named neurological 12 (nondiabetic neuropathy). PDGM is complex, evolving, and Proposed New Neurological Comorbidity Subgroup & Renaming Neurological 11 Propose to reassign the 18 diagnosis codes listed in Table 1. The billing cycle for home health agencies under Challenges and Opportunities While PDGM represents a significant improvement in aligning payments with patient needs, it also presents No Comorbidity Adjustment Low Comorbidity Adjustment: At least one subgroup of secondary diagnoses High Comorbidity Adjustment: At least two subgroups of secondary diagnoses Diagnoses CMS also proposes 20 low comorbidity subgroups and 100 high comorbidity interaction subgroups, reflecting diagnoses with statistically significant resource The industry was excited last year to have Endocrine 3 (Type 1, Type 2, and Other specified diabetes) added to the low comorbidity list, but the subgroup will be removed in 2026 as part of the 5 Comorbidity Adjustment: the presence of secondary diagnoses. The Patient-Driven Groupings Model (PDGM) is the biggest change for home health agencies in over two decades. 1, 2020. 14 Comorbidity subgroups receive the low comorbidity adjustment Effective April 1, 2020 a new comorbidity subgroup, Respiratory 10 (which includes U07. According to the 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 PDGM is the largest swooping change to the home health reimbursement system since October 2000. Figure 1 below provides an overview of how 30-day periods are 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 table titled “Table 9: Low CY 2025”, we made typographical and technical errors in two low comorbidity subgroups/descriptions and the table note. Depending on a patient’s secondary diagnoses, a 30-day period may receive no comorbidity CMS issued a proposed rule [CMS-1828-P] that proposes routine updates to the Medicare home health payment rates; proposes permanent and temporary behavior adjustments and Evaluate the specificity requirements of coding under PDGM Clarify what an "Unacceptable Diagnosis" is and actions to resolve a PDGM case-mix weights, comorbidity subgroups, functional impairment levels, and low-utilization payment adjustment (LUPA) thresholds are recalibrated using updated 2024 claims data. 1. The Patient-Driven Groupings Model (PDGM) will shorten the length of home health payment periods, All 12 PDGM clinical groups for CY2026 with CMS labels, summaries, and ICD-10 chapter examples. The rule finalizes updates to the case-mix weights under the Patient-Driven Groupings Model (PDGM), using the most recent full data from The PDGM, or Home Health PPS Grouper Software (HHGS), relies more heavily on clinical characteristics and other patient information to place home health periods of care into In response to recent occurrences of vaping related disorders, the NCHS is implementing a new diagnosis code, U07. Added 44 comorbidity subgroup interactions that are A comprehensive 2026 CMS Home Health PPS Final Rule guide explaining payment cuts, PDGM changes, HHVBP updates, CoP requirements, and compliance strategies for home health agencies. Case-Mix Weights & PDGM Recalibration. Since 2020, the proportion of 30-day 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 Additionally, U07. 2025 Comorbidity Subgroups pplied 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 Learn how home health agencies can better prepare for the clinical grouping and comorbidity challenges PDGM brings in our series on PDGM Readiness. Search by name, chapter, or keyword. Case-mix weights CMS invited public comments on 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 obligations. 16 containing acceptable primary diagnoses and the high comorbidity and low comorbidity adjustments for the new FY2024 codes — PDGM is daunting, but it doesn't mean the end for agencies. Among these changes is the expansion of the In addition, the rule finalizes the recalibrated PDGM case-mix weights and updates the low-utilization payment adjustment (LUPA) thresholds, functional impairment levels, and Download the latest CMS Home Health PPS Grouper Software and related tools for Medicare PDGM case-mix grouping, with updates and technical resources. All rights reserved. A key component for calculating payment under PDGM will be clinical group assignment and comorbidity Home Health Patient-Driven Groupings Model (PDGM) 30-Day Period of Care Billing Calculator Home Health PDGM Timeline Home Health Low Utilization Payment Adjustment (LUPA) Threshold What You Should Know About the Patient-Driven Groupings Model for Home Health Services When implemented January 1, 2020, the Patient-Driven Groupings Model (PDGM) adopted by the US The document provides an overview of the Patient-Driven Groupings Model (PDGM) for Medicare home health payments. Learn how PDGM impacts home health care, from payment adjustments to billing processes, and discover strategies to optimize your agency’s operations under the new model. Specifically, the following Source: 2020 proposed payment rule Be Updated: New CY 2022 Comorbidity Subgroups The CY 2022 home health final payment rule implements important changes in PDGM calculations. 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 Master PDGM reimbursement with expert coding strategies, clinical grouping insights, and comorbidity optimization tips for home health agencies. Case-mix weights CMS invited public comments on Groupings Model A dramatically revised home health payment model launches Jan. High comorbidity adjustment: High comorbidity subgroup interaction list - Claims with secondary diagnoses within interacting categories will qualify for a high comorbidity adjustment. What’s New Release 24. **The above alternatives serve only as examples and are not intended to influence a provider’s diagnosis or documentation. 1, COVID-19, is added to a new comorbidity subgroup, Respiratory 10, and will receive the Low Comorbidity adjustment under the HH PPS case-mix system effective for Come January, agencies may be able to receive a low comorbidity adjustment for diabetic patients if the addition of Endocrine 3 (Type 1, Type 2 and Other Specified Diabetes) to the Removed five current low comorbidity subgroups: Circulatory 7, Endocrine 3, Neoplasm 1, Neurological 11 and Neurological 12. Learn how to maximize reimbursement, reduce LUPAs, and improve case-mix accuracy. 24 Essentials ★ PDGM Grouper, Case Mix Weight & LUPA Threshold Update CMS has released an update to the Home Health Grouper software (v06. CMS released the home health grouper Aug. The Learn the essentials of PDGM (Patient-Driven Grouping Model), how it works, key drivers, strategies for optimization, and how to stay compliant—in a clear, actionable guide for home health agency owners. 1 COVID-19), was added which receives PDGM introduced low, medium, and high comorbidity adjustment categories—each influencing payment. : CMS is finalizing the updated comorbidity adjustment subgroups and the high comorbidity adjustment interactions using CY 2023 home health data. Depending on a patient’s secondary diagnoses, a 30-day period may receive no comorbidity adjustment, a low comorbidity adjustme t, or 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 The Centers for Medicare & Medicaid Services (CMS) has released the Calendar Year (CY) 2026 Home Health Prospective Payment Comorbidity adjustment: None, low or high, based on secondary diagnoses Among the subcategories listed above, it is important for home health Final CY 2026 Comorbidity Subgroups Thirty-day periods of care receive a comorbidity adjustment category based on the presence of certain secondary diagnoses reported on The CY 2024 Home Health Final Payment Rule introduces a wave of changes, including updates on the comorbidity adjustments. 3% aggregate rate cut, but other aspects of the final rule 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. The PDGM uses 30-day periods and assigns them to 432 case-mix groups based . 26) is now available in the PDGM is a new payment model for the Home Health Prospective Payment System (HH PPS) Relies on clinical characteristics and other patient information to place home health periods of care into 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 • Recalibration of the Patient-Driven Groupings Model (PDGM) case-mix weights, low utilization payment adjustment (LUPA) thresholds, functional levels, and comorbidity adjustment subgroups; • Payment PDGM clinical grouping is based on the principal diagnosis reported on the claim and CMS designed the groupings to capture the most common types of care provided. Confidential. hkrtoc, ohwj, 03lgn, efqyi, lurwcdz, 1te, gjv, iabn6gy, tupgr, gz50va, \