Comorbidity Adjustments

On November 4^th, CMS posted an updated Grouper Tool in order to capture the changes that will be effective on January 1^st, 2025, regarding low and high comorbidity adjustments. 

For fiscal year 2025, there are 22 Low comorbidity adjustments (same number as 2024) and 97 High comorbidity adjustments (down from the 102 in 2024).  Low comorbidity adjustments changes are as follows: Neurological 4 which includes Alzheimer’s disease and related dementia diagnoses and Respiratory 10 which included COVID-19 have been removed and will no longer garner a low comorbidity adjustment when noted in slot 2-25 of the claim.  Endocrine 3 which includes diagnoses of Diabetes Mellitus Type 1, 2, and other specified diabetes and Gastrointestinal 2 which includes Intestinal Obstruction and Ileus have been added.  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.  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 high comorbidity adjustments are not so easily understood.  34 potential high comorbidity adjustments were added for 2025 and 42 were deleted from this potential revenue bump. 

The high comorbidity adjustment conditions include, just to name a few, a revenue increase for having both depression and a non-pressure chronic ulcer/pressure ulcer as well as the increased likelihood of a high comorbidity adjustment due to multiple interactions with the sequela of cerebrovascular diseases, including cerebral atherosclerosis and stroke sequelae.  There are increased opportunities for a high comorbid adjustment when a patient has both varicose veins and/or lymphedema in addition to one of the following: hypertensive chronic kidney disease, hypothyroidism, heart failure, or cellulitis.  Remember these comorbid diagnoses for a high adjustment only occurs with the interaction of both diagnoses when they are in slot 2-25 on the claim.

Under the 2025 recalibrated case-mix weights, the difference between no comorbidity and a low comorbidity adjustment is $128 per 30-day billing period and the difference between a low and high comorbidity adjustment is $307 per 30-day billing period before application of any wage-index adjustments.

Most importantly, the Diagnosis Code Clinical Group Assignments for F01.50 Vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety has been altered and may now be used as a primary diagnosis in home health falling into the Behavioral Health Clinical Group.   It was originally proposed that only vascular dementia with noted behavioral disturbances, or severity could be listed as primary.  While it is still best practice to follow ICD-10-CM coding guidelines and Code First the causal condition, if applicable (known), it is no longer mandatory and frees up the coder to proceed with the chart without the burden of timely queries.

A summary of the changes can be found following this link to the zip file:  https://www.cms.gov/files/zip/jan-2025-hh-pps-grouper-software-hh-pdgm-v06025-posted-11/04/2025.zip