PDGM – Comorbidity Adjustment

The PDGM includes a comorbidity adjustment category based on the presence of secondary diagnoses. 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. Home health 30-day periods of care can receive a comorbidity adjustment under the following circumstances:

  • Low comorbidity adjustment: There is a reported secondary diagnosis that is associated with higher resource use, or;

  • High comorbidity adjustment: There are two or more secondary diagnoses that are associated with higher resource use when both are reported together compared to if they were reported separately. That is, the two diagnoses may interact with one another, resulting in higher resource use.

  • NO comorbidity adjustment:If your claim does not have reported comorbidities that fall into one of the Comorbidity subcategory chart below, there would be no comorbidity adjustment applied.

Use this comorbidity loop up tool to determine if a specific comorbidity dx code falls into the Comorbidity subcategory chart below for CMS to consider a comorbidity adjustment which would increase your payment.

 

Comorbidity Subgroup Chart

Comorbidity Subgroups
 Cerebral4
 Circulatory10
 Circulatory9
 Heart10
 Heart11
 Neoplasm1
 Neuro10
 Neuro11
 Neuro11
 Neuro5
 Neuro7
 Skin1
 Skin3
 Skin4