Physicians/Specialists
Facilities/Hospitals
Ancillary
Publication Date: 
2019-12-31

In November, the Centers for Medicare and Medicaid Services (CMS) ruled that certain reimbursement changes for the Home Health Prospective Payment System (HHPPS) will be required in 2020.

Key Points

  • These changes affect only those providers who contract with Blue Medicare on a Prospective Payment System (PPS) basis.
  • Providers who are reimbursed per-day or per-treatment are not affected by these changes.
  • These reimbursement payment changes are effective January 1, 2020.
  • Payments will be based on the new Patient-Driven Groupings Model (PDGM) rather than the current Home Health Resource Groups (HHRG).
    • PDGM HHPPS codes are a five-character, case-mix grouping, which better reflect clinical and patient characteristics.
    • Coding will be based on a 30-day period of care, rather than a 60-day period of care.
  • Authorization processes for home health services will not be affected.
  • Claims filing will also not be affected, as PDGM codes will replace the HHRG codes on claims.
  • Blue Cross and Blue Shield of North Carolina will complete the installation and testing for the PDGM pricing process early in the first quarter of 2020. Minimal delays are expected for the processing and payment of claims with dates of service on/after January 1, 2020.