Initial COVID-19 Results Under Medicare PDGM

By Chris Attaya
December 02, 2020 Home Health

It continues to be concerning to watch the latest surge in COVID-19 cases this fall amidst all the uncertainty in caring for patients under this pandemic. Home Health and Hospice agencies should be commended for their heroic efforts to attend to these patients in their own homes. With the virus erupting this year from virtually nowhere, effective April 1st 2020, CMS embraced the new ICD-10 code (U07.1) by adding it to the MMTA-Respiratory Clinical Group to reimburse home health agencies for these patients. I was curious to see how the PDGM model aligned specifically to these patients.

To help benchmark and track these patients, the team at SHP added a new Primary Diagnostic Category that represents this single new diagnosis code. That way, many of the SHP reports can be segmented to break out COVID-19 patients in a number of different ways. In comparing the first seven months that COVID-19 coding has existed (April – October 2020) against the SHP National Database, 1.9% of all Medicare PDGM 30-day period starts have COVID-19 as a primary diagnosis code. There are differences depending on which CMS region your agency is located in. The Northeast region, which is the original epicenter of the virus and includes the states of New York and New Jersey, has the highest rate at 3.9%.

Medicare Percent of 30-Day Periods Region I - New England Region II - Northeast Region III - East Region IV - South Region V - Central Region VI - Southwest Region VII - Midwest Region VIII - Mountain Region IX - West Region X - Northwest
COVID-19 1.8% 3.9% 1.9% 1.9% 2.1% 1.4% 2.1% 1.5% 1.6% 1.1%

For these seven months, COVID-19 was the 12th most frequently utilized primary diagnosis code used in Medicare 30-day period starts. As a percent of all 30-day period starts, October 2020 had the highest rate at 2.3%.

Regarding the PDGM Comorbidity and Functional Impairment components, our analysis found differences when comparing the SHP national database among the “High” levels (see table) of each group. COVID-19 patients have fewer interactions among the comorbidity subgroups (3.5% lower) leading to a fewer patients with a “High” comorbidity adjustment, but more patients with a “High” functional impairment level (6.5% higher) when compared to the SHP National database.

Comorbidity Adjustment SHP COVID-19
None 47.2% 52.3%
Low 38.0% 37.4%
High 14.8% 10.3%
Total 100.0% 100.0%
Functional Impairment    SHP COVID-19
Low 24.3% 19.3%
Med 31.8% 30.2%
High 43.9% 50.4%
Total 100.0% 100.0%

Source: SHP National Database: April – Oct 2020 (Run as of 11/9/20)

The PDGM Source and Timing components are interesting to track across the months of April through October. In the first month, COVID-19 has the highest percentage of “Institutional Early” reflecting the higher proportion of “Early” patients coded with U07.1 for the first time, as well as higher “Institutional” referrals as a result of many hospitals discharging patients home to free up bed capacity. This ratio decreases as initially admitted patients enter into late periods but you can see a second surge of COVID-19 patients in July where the “Institutional Early” percentage increases by 13.6% from June to July, and again from September to October with an increase of 17.6%.

Source & Timing April May June July August September October
Community Early 8.0% 7.1% 5.4% 7.9% 6.8% 5.8% 9.2%
Community Late 3.2% 35.4% 48.1% 32.0% 39.9% 45.8% 25.0%
Institutional Early 78.1% 49.9% 40.0% 53.6% 46.9% 42.9% 60.5%
Institutional Late 10.7% 7.7% 6.5% 6.4% 6.4% 5.5% 5.2%
Total 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

I also looked at the first 5 months of claims data (April – Aug) to account for any delayed claims billing biases. Measured against all periods billed, COVID-19 patients are approximately 8% higher in case-mix weight (1.127 vs 1.051) and period revenue ($1,926 vs $1,780), mostly reflecting the higher proportions of "Early" and "Institutional" periods compared to the national database. The LUPA rate for COVID-19 patients is also higher by 3.3% points (12.1% vs 8.8%). Finally, average visits per period are slightly lower than the SHP national average (8.36 vs 8.49).

These are unprecedented times. Let’s hope for some relief following the upcoming approval and distribution of the COVID-19 vaccine. At SHP, our team will continue to look for ways to support your agencies through these uncertain times.

About the Author
Chris Attaya
Chris Attaya
VP of Product Strategy
With more than 30 years of experience in the home health and hospice industry, Chris is responsible for product development and helping clients achieve increased operational and financial performance.