Pdgm Comorbidity Adjustment Table, The PDGM Model includes a comorbidity adjustment based on the presence of a secondary diagnosis.

Pdgm Comorbidity Adjustment Table, Uses the presence of home health specific comorbidities as part of the overall case-mix adjustment. Refresh PDGM knowledge. 08% increase in case-mix from No to Low 5 Comorbidity Adjustment: the presence of secondary diagnoses. 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 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. Review functional scoring and comorbidity logic before recalibration goes live. The comorbidity adjustment has three levels: The case mix weight is increased by 6. No secondary diagnoses exist, or none meet the criteria for a low or high comorbidity adjustment. 01% with a Low Comorbidity adjustment and an additional 12. lead to high comorbidity adjustments under PDGM. 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. Audit The PDGM includes a comorbidity adjustment category based on the presence of secondary diagnoses. Jul 30, 2024 · Up to 25 diagnoses will fit in the electronic claims file. 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. The PDGM Model includes a comorbidity adjustment based on the presence of a secondary diagnosis. The changes are intended to more accurately capture real-world resource utilization patterns for patients with multiple conditions. 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. The home health specific comorbidity list includes 13 broad categories with 116 subcategories. Claims with secondary diagnoses within interacting categori. 95% if a High Comorbidity adjustment applies. 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. E. 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. 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. Learn more about the comorbidity adjustment category of the PDGM and how it applies to your home health agency. Timing of the 30-day period (two subgroups): early or late. of this final rul , we update the home health wage index. The comorbidity adjustment in PDGM can increase pa. 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. Nov 30, 2025 · While a table of contents has been provided, page numbers are added. Tighten NOA workflows. Admission source (two subgroups): community or institutional admission source. Shorten your reporting cycle. The following table identifies the Economic Costs And Transfers. 4% overall adjustment. 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 rule does provide helpful final decision sections. HIGH comorbidity adjustment interaction subgroups The chart below lists the subgroups tha. Prepare for a possible 45-day QRP submission window. 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. impairment levels, and comorbidity adjustment subgroups. . Jan 30, 2026 · CMS updated the PDGM comorbidity adjustment subgroups using 2024 home health claims and OASIS data. 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