Which New Subgroup Was Added To The Pdgm Low Comorbidity List In 2026, CMS recalibrated case‑mix weights, refreshed functional impairment levels and comorbidity subgroups, and adjusted LUPA thresholds (many by one visit). 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 home health claims with From Dates on or after April 1, 2020 and included in the Home Health Patient-Driven Groupings Model (HH PDGM) Grouper software package, v01 The PDGM Model includes a comorbidity adjustment based on the presence of a secondary diagnosis. It reassigns 37 diagnosis codes to a different comorbidity subgroup when listed as a secondary diagnosis. High comorbidity adjustment: There are two or more secondary diagnoses on the home health- both are reported together compared to when they are reported separately. Explain the CY 2026 proposed PDGM changes, including recalibration of case-mix weights, updates to comorbidity subgroups, and functional impairment scoring. The changes are intended to more accurately capture real-world resource utilization patterns for patients with multiple conditions. Jan 30, 2026 · CMS updated the PDGM comorbidity adjustment subgroups using 2024 home health claims and OASIS data. Specifically, the following diagnoses will be removed from the low comorbidity adjustment subgroup. Low Comorbidity Subgroups Additions Reason Key: A=Added To List, N=New Code Low Comorbidity Subgroups Removals The following Comorbidity Subgroups are removed from being applicable for a low comorbidity adjustment. Learn how clinical groupings and comorbidity will be affected. Dec 2, 2025 · In addition, this rule finalizes the recalibrated PDGM case-mix weights and updates the low-utilization payment adjustment (LUPA) thresholds, functional impairment levels, and comorbidity adjustment subgroups under sections 1895 (b) (4) of the Act for 30-day periods of care in CY 2026. Dec 5, 2025 · Adopting several new and revised provider enrollment provisions that the CMS believes will help reduce improper Medicare payments and protect beneficiaries. 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. The following will be completely removed from the low comorbidity calculation: musculoskeletal 1 diagnoses respiratory 9 diagnosis The following will be added to the secondary low Nov 6, 2024 · In addition, the rule finalizes the recalibrated PDGM case-mix weights and updates the low-utilization payment adjustment (LUPA) thresholds, functional impairment levels, and comorbidity adjustment subgroups under section 1895(b)(4)(A)(i) and (b)(4)(B) of the Act for 30-day periods of care; finalizes the proposal to adopt the most recent Office of Management and Budget (OMB) Core-Based Aug 23, 2022 · The proposed rule reassigns 320 diagnosis codes to a different clinical group if they are listed as primary. Additionally, U07. 28. Low comorbidity adjustment: There is a reported secondary diagnosis on the home health-specific comorbidity subgroup list that is associated with higher resource use. The PDGM includes a comorbidity adjustment category based on the presence of secondary diagnoses. 1 COVID-19), was added which receives a low comorbidity adjustment. Additionally, 159 diagnosis codes are going to be completely removed from the list of acceptable primary diagnoses under PDGM. Nov 28, 2025 · In addition, it updates the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP). Home Health providers are very clear on the increased resource utilization and care required by the agency when diabetes is a part of the plan of care. The MHA will provide members with an updated impact analysis in the next several weeks. Jan 5, 2026 · 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 changes finalized in the 2026 home health payment final rule, released Nov. Updates on Comorbidity Subgroups In the proposed rule, there are 23 subgroups for low comorbidity adjustments and 94 high comorbidity adjustments, compared to the present number of 20 and 87 subgroups respectively. Diagnosis coding and OASIS ADL data are two significant areas that the agency can impact by gaining a deeper understanding of both items. 14 Comorbidity subgroups receive the low comorbidity adjustment Effective April 1, 2020 a new comorbidity subgroup, Respiratory 10 (which includes U07. Jan 30, 2026 · Low Comorbidity Adjustment Subgroups In 2024, there will still be 22 Low Comorbidity Adjustment Subgroups, but significant changes are underway. Nov 18, 2025 · Describe the FY 2026 ICD-10-CM updates, including new, revised, and deleted codes, and explain their relevance to home health coding and documentation. Of those 116 subcategories, 13 are included in the comorbidity adjustment of the PDGM: Analysis of subgroups was completed to determine which interactions (diagnoses from two subgroups) had increased Jul 30, 2024 · Transitioning to the Patient-Driven Groupings Model (PDGM) has already begun to impact operations for home health agencies. The home health specific comorbidity list includes 13 broad categories with 116 subcategories. This implies that if any of these diagnoses are now listed as comorbidities in slots 2-25, you will no longer be eligible for a low comorbidity While losing Neurological 4 diagnoses as a low comorbid adjustment is a hit to the industry, it is certainly a win to see that Diabetes has been added as a low comorbidity adjustment. Jan 5, 2026 · Operationally, PDGM shifts again in 2026. Source: 2020 proposed payment rule No Comorbidity Adjustment Low Comorbidity Adjustment: At least one subgroup of secondary diagnoses High Comorbidity Adjustment: At least two subgroups of secondary diagnoses. 7ebs lcn xy5jc5 fuyi2 uczk bo5buven rxc 0cu3xc je j7bmum