The healthcare landscape is constantly evolving, and staying informed about changes is crucial, especially within the home health sector. A significant shift occurred with the introduction of the Patient-Driven Groupings Model (PDGM) by the Centers for Medicare & Medicaid Services (CMS). Understanding PDGM is essential for home health agencies to navigate reimbursement and provide effective patient care. At the heart of PDGM are 12 Diagnosis Groups For Home Health Care, which are pivotal in determining payment and care delivery. This article breaks down these 12 diagnosis groups, offering a comprehensive overview for healthcare professionals and anyone seeking clarity on home health care classifications.
Understanding the PDGM and its 12 Clinical Groups
The Home Health Prospective Payment System (HH PPS) underwent a major transformation with the implementation of PDGM on January 1, 2020. PDGM shifted the focus from therapy utilization to patient characteristics and clinical needs to categorize home health periods of care. This new model emphasizes clinical groupings, among other factors, to create meaningful payment categories. One of the core components of PDGM is the assignment of a principal diagnosis to one of 12 clinical groups, reflecting the primary reason a patient requires home health services.
These 12 diagnosis groups for home health care are not arbitrary; they are carefully designed to represent distinct clinical areas requiring home health intervention. By categorizing patients into these groups, PDGM aims to create a more equitable and patient-centered payment system, ensuring that agencies are appropriately reimbursed based on the complexity and needs of their patient population.
The 12 Clinical Diagnosis Groups Explained
Within the PDGM framework, 30-day periods of care are classified into a possible 432 case-mix groups. A critical factor in this classification is the clinical grouping, which consists of these 12 subgroups:
-
Musculoskeletal Rehabilitation: This group encompasses patients needing rehabilitation for musculoskeletal conditions. This could include recovery from joint replacement surgery, fractures, arthritis management, and other conditions affecting muscles, bones, and joints. Home health care in this group focuses on physical therapy, occupational therapy, and nursing support to restore mobility and function.
-
Neuro/Stroke Rehabilitation: Patients in this category require specialized rehabilitation following neurological events such as stroke, traumatic brain injury, or other neurological disorders. Care involves intensive therapy to regain motor skills, speech, cognitive function, and adapt to changes in functional abilities. Home health services are crucial for continued recovery in a familiar environment.
-
Wounds: This clinical group addresses patients with various types of wounds, including pressure ulcers, surgical wounds, diabetic ulcers, and other complex wounds requiring skilled nursing care. Home health focuses on wound assessment, dressing changes, infection prevention, pain management, and patient education on wound care.
-
Medication Management, Teaching, and Assessment – Surgical Aftercare (MMTA – Surgical Aftercare): This group is for patients requiring home health services primarily for medication management, teaching, and assessment following surgical procedures. It includes monitoring surgical sites, managing pain medications, educating patients on medication regimens, and assessing for post-operative complications.
-
Medication Management, Teaching, and Assessment – Cardiac and Circulatory (MMTA – Cardiac and Circulatory): This category includes patients with cardiac and circulatory conditions such as heart failure, hypertension, and other cardiovascular diseases. Home health focuses on medication management related to these conditions, patient education on diet and lifestyle modifications, and monitoring for signs and symptoms of cardiac decompensation.
-
Medication Management, Teaching, and Assessment – Endocrine (MMTA – Endocrine): This group encompasses patients with endocrine disorders, primarily diabetes mellitus and thyroid disorders. Home health care includes medication management, blood glucose monitoring, insulin administration teaching, dietary education, and foot care for diabetic patients.
-
Medication Management, Teaching, and Assessment – Gastrointestinal Tract and Genitourinary System (MMTA – Gastrointestinal Tract and Genitourinary System): This category covers patients with conditions affecting the digestive and urinary systems. Care may include medication management for conditions like urinary tract infections, bowel disorders, and teaching patients about ostomy care or managing gastrointestinal symptoms.
-
Medication Management, Teaching, and Assessment – Infectious Disease, Neoplasms, and Blood-Forming Diseases (MMTA – Infectious Disease, Neoplasms, and Blood-Forming Diseases): This broad group includes patients with infectious diseases, cancer (neoplasms), and blood disorders. Home health services are varied and may include medication management for infections, pain and symptom management for cancer patients, and monitoring for complications related to blood disorders.
-
Medication Management, Teaching, and Assessment – Respiratory (MMTA – Respiratory): Patients with respiratory conditions like COPD, pneumonia, and asthma fall into this group. Home health focuses on medication management for respiratory illnesses, oxygen therapy management, teaching breathing techniques, and assessing respiratory status. Notably, the ICD-10-CM codes U07.1 (COVID-19) and U07.0 (Vaping-related disorder) are also assigned to this MMTA-Respiratory clinical group.
-
Medication Management, Teaching, and Assessment – Other (MMTA – Other): This is a residual category for patients whose primary diagnosis for home health care doesn’t fit into the other more specific MMTA groups. It can include a variety of conditions requiring medication management, teaching, and assessment that are not primarily surgical, cardiac, endocrine, gastrointestinal/genitourinary, infectious disease/neoplasm/blood-forming disease, or respiratory in nature.
-
Behavioral Health: This group is dedicated to patients requiring home health services for behavioral health conditions such as depression, anxiety, and other mental health disorders. Home health in this category may involve medication management, therapy, and support to improve mental well-being and daily functioning within the home environment.
-
Complex Nursing Interventions: This category is for patients who require complex skilled nursing care that goes beyond routine medication management and assessment. This might include patients needing specialized procedures, intensive monitoring, or management of multiple comorbidities requiring a high level of nursing expertise in the home setting.
Factors Beyond Clinical Groupings
While these 12 diagnosis groups for home health care are a cornerstone of PDGM, they are not the only factors determining case-mix adjustment and payment. Other key elements include:
- Admission Source: Whether the patient is admitted to home health from the community or an institutional setting (like a hospital or skilled nursing facility) influences the payment.
- Timing of the 30-day Period: The payment also varies depending on whether the 30-day period is considered “early” or “late” in the episode of care.
- Functional Impairment Level: Patients are categorized into low, medium, or high functional impairment levels, impacting the case-mix adjustment based on their functional needs.
- Comorbidity Adjustment: The presence of secondary diagnoses (comorbidities) further adjusts the payment. There are categories for no comorbidity, low comorbidity, and high comorbidity.
Combining these categories – 2 admission sources, 2 timing periods, 12 clinical groups, 3 functional impairment levels, and 3 comorbidity adjustments – results in the 432 possible case-mix adjusted payment groups under PDGM.
Conclusion: Navigating Home Health Diagnosis Groupings
Understanding the 12 diagnosis groups for home health care under PDGM is crucial for home health agencies, clinicians, and anyone involved in the home health industry. These groupings provide a framework for classifying patients based on their primary clinical needs, contributing to a more nuanced and patient-centered payment model. By focusing on these clinical categories, PDGM aims to ensure appropriate reimbursement for the diverse care needs of patients receiving home health services. Staying informed about these classifications and their implications is vital for delivering high-quality, effective home health care in today’s evolving healthcare system.
