Determining which alerts and tools matter to your organization
by Holly Hester
June 13, 2019

When the Patient-Driven Groupings Model (PDGM) launches Jan. 1, 2020, leveraging tools and resources to ensure compliance will be critical to a successful transition. Home health care providers already have one helpful tool in place: the electronic health record (EHR). By incorporating workflow efficiencies, alerts, customizable features and feedback reporting capabilities, EHRs can provide visibility into a provider’s documentation, coding and billing practices for PDGM and for compliance with federal, state and payer regulations.

Diagnostic Coding

Accurate diagnosis coding is important in PDGM, particularly when it comes to selecting the principal diagnosis, which represents the primary reason for home health services and determines the clinical grouping component. The Centers for Medicare & Medicaid Services (CMS) has indicated that if an ICD-10 code that does not correlate to one of the 12 PDGM clinical groups is used as the principal diagnosis, the claim will be returned to the provider to be recoded.

The principal diagnosis on the claim should match the primary diagnosis entered in item M1021 on the Outcome and Assessiment Information Set (OASIS). Integrity checks in the EHR can notify the clinician if these codes are not identical, providing an opportunity to review and correct information. Alerts within the EHR indicating diagnosis codes that do not correlate to a PDGM clinical group allow providers the opportunity to recode the claim before it is submitted. Agencies may wish to turn on or activate this alert functionality now to provide insight into current coding practices.

Secondary diagnoses on the OASIS and the claim represent comorbidities and complexities that impact the care provided to the patient. In developing PDGM, CMS identified certain comorbidity subgroup interactions that require additional resources to treat and manage. If these conditions are coded as secondary diagnoses on the claim, the home health payment period may receive a comorbidity adjustment under PDGM, deemed either high or low based on resource use.

Reporting Patterns

Reports within the EHR give insight into current diagnostic coding practices and patterns to allow home health agencies to identify educational opportunities related to coding both primary and secondary diagnoses on the claim and the OASIS. Providers can analyze trends in code utilization to determine if current coding practices translate to success under PDGM.

Information such as the percentage of episodes returned to a provider, the percentage of patients per clinical grouping, the percentage of those patients with secondary diagnoses that qualify for a comorbidity adjustment, and percentage of patients with no comorbidity adjustment provide key information about an agency’s current patient mix and whether or not diagnosis coding accurately reflects the medical needs and complexity of the patient population under today’s payment system and under PDGM.

Compliance Metrics

As the industry transitions to a payment model focused on patient characteristics rather than on services provided, it is essential to ensure that clinical documentation paints an accurate picture of the patient and is reflected clearly in the OASIS. OASIS items and questions can be embedded into the EHR’s initial skilled nursing or therapy assessment, allowing the system to incorporate proactive comparisons of documentation and OASIS items—and to identify potential discrepancies between clinical documentation and item coding.

For example, if a patient has injectable insulin documented on the medication list but a diabetes diagnosis isn’t listed in the OASIS, or if a patient has a rheumatoid arthritis diagnosis but no pain is reported, the EHR can alert the clinician of the inconsistency via integrity checks. These warnings allow the clinician the opportunity to review the record, observe and assess the patient and ensure all items submitted to CMS via the OASIS are clearly supported in the medical record. This is important in today’s home health prospective payment system and will continue to be important under PDGM.

Tracking scheduled and completed visits is another key compliance metric in home health. Providers and agencies need to know the number and type of visits scheduled for and provided to the patient to ensure compliance with visit frequency orders and to monitor the low utilization payment adjustment (LUPA) threshold for accurate billing and reimbursement. Under PDGM, the LUPA thresholds are established for each 30-day payment period (versus for a 60-day episode) and vary for each home health resource group. Calendar or schedule functionality within an EHR helps with order compliance and visit tracking. Reports can be generated to track payment periods under the PDGM LUPA thresholds.

EHRs allow providers to determine mandatory fields within the system so items critical to claim submission and reimbursement are completed accurately and on time. For example, you can make sure that the home health certification and plan of care (CMS 485) can’t be submitted to the physician for signature without documentation of the required face-to-face visit, or require that all orders be signed prior to claim submission. Mandatory fields may be set for primary and secondary diagnoses and the OASIS functional items to ensure that the information required for PDGM classification is complete.

CMS Tools

CMS has published two tools to help providers prepare for PDGM:

  • The agency-level impacts file compares overall financial performance under the current payment system and PDGM. While understanding this overall financial impact can be helpful, the information isn’t actionable without insight into the corresponding clinical and coding details of the agency’s current practice and how that drives performance in PDGM.
  • The PDGM grouper tool allows individual patient-specific information to be entered into the tool—including primary and secondary diagnosis, functional level, timing and admission source—and then uses this information to generate a PDGM health insurance prospective payment system (HIPPS) code and case-mix weight. It does not, however, factor in outliers or partial payments, nor does it convert the HIPPS code to a payment amount. An EHR with PDGM analytics capabilities allows providers to take this process further by offering real-time comparison of current OASIS and claims data in the current payment system and PDGM from both a clinical and financial perspective at an agency and patient level.

Jan. 1, 2020, will be here soon. Now is the time to determine which EHR alerts, settings and reports are meaningful to you and to work with your vendor to identify your EHR’s capabilities and your needs, both today and under PDGM.