The
process of coding and OASIS (Outcome
and Assessment Information Set) review plays a critical role in
profitability of home health organizations. Accuracy and timely completion can
help agencies achieve the right balance, and support maximum reimbursement,
under Patient-Driven Groupings Model (PDGM).

In fact,
coding and OASIS review done right will help home health providers lower costs
and uphold quality, while facilitating maximum returns in revenue — returns
that reflect the true nature of care and services provided.

Here is a
look at the three-step process needed to improve the revenue cycle through
coding and OASIS review.

Review the components of PDGM

PDGM was
supposed to be the story of 2020. Obviously, that changed with the COVID-19
pandemic. And yet the pandemic increased the need for home health agencies to
understand PDGM down to a molecular level. Clinical groupings, comorbidity
adjustment, physician clinical notes, plan of care — under PDGM, all of these
elements figure into reimbursement rates.

“Under
PDGM, three-fifths of your revenue will be driven by accurate coding and
OASIS,” says J’non Griffin, president of Home Health Solutions, A Simione
Coding Company. “There are other components to that, like the face-to-face
documentation, but the eye of the coder needs to be on the focus of care, and
that includes more than the piece of paper from the doctor but also what’s
happening in the agency.”

To
capture all of this data accurately and hence maximize reimbursement,
communication between the clinical department and the coders is essential.
Coders must be able to get as much data as possible upfront to reduce the
amount of time that billing then spends going back to check that work.

Thus, the
intake department has become exponentially important under PDGM, because that
department is getting the ball rolling with data collection, starting with the
patient’s admission source and timing, primary diagnosis, functionals and
comorbidities. Another major component under PDGM is visit utilization. Under
the Prospective Payment
System (PPS), reimbursement was a simple math equation: as therapy volume rose,
so did reimbursement.

PDGM relies on quality, not quantity.
Therefore it is imperative that agencies know everything there is to know about
patients, because that data lets agencies operationalize correctly, and code
correctly, placing patients in the correct comorbidity grouping, leading to
them being placed in the right level of care for the purposes of coding. If
agencies fail to do that, it doesn’t matter how sick the patient is or how many
visits the agency provides.

“You’re going to lose your shirt quickly
in this model,” Griffin says.

Maximize
reimbursement by understanding clinical groups

According to the National Council on
Aging, approximately 77% of older adults have more than one chronic disease.
That means that in order to maximize reimbursement under PDGM, agencies must
know the difference between the different clinical groupings and know at what
level each chronic condition is reimbursed.

PDGM has 12 reimbursement rates for
clinical groupings. The highest is wounds, at $2,470 per period. Much lower on
the list is MMTA Other, with a reimbursement rate of $2,037. Medicare dictates
that if a patient presents two equal health concerns, the agency can select the
one to focus on for that 30-day period.

“Therefore, your supporting documentation
must reflect the utilization, specifically in the areas of clinical grouping,
functional status and comorbidities,” says Robert V. Simione, director of
financial consulting for Simione Healthcare Consultants.

In the example of a patient with
congestive heart failure who is also in need of wound care, the agency can
prioritize the wound care in the documentation for the first 30 days, while
addressing the heart disease secondarily. Then, in the next 30-day period, the
caregiver knows what to do with the wound care, and can now focus on the heart
— thus letting the agency change its documentation for that period.

“Likely you’re teaching both at the same time, but
now our intensity and focus has changed from wounds to the congestive heart
failure,” Griffin says.

Document patient acuity to meet the number of visits provided

One of
the major changes for PDGM was an anticipated decline in Low Utilization
Payment Adjustment (LUPA) rates — the standardized, per-visit payments for care
episodes that fall under a certain visit threshold. That would have been a
benefit to agencies, but instead, COVID-19 has fueled a rise in LUPAs, as more
patients refuse at-home visits.

In fact,
in a survey this year from National Association for Home Care & Hospice
(NAHC), 47% of home health respondents said their agency saw LUPAs double, if
not more, due to the pandemic.

That
gives agencies another key area to monitor and manage.

“The
clinical manager role is one of the most critical roles in PDGM,” Simione says.
“You have to give them the tools and the dashboards and the analytics to
measure this to find opportunities.”

These
clinical managers must understand that what drives a successful home health
business under the still young payment model is therapy utilizations. Low
visits count combined with a high-acuity patient is the preferred equation,
while the opposite — high visits with a low-acuity patient — is not.

“That’s
what you have to start training the clinical manager to look at,” Simione says.
“It’s that next level of analysis that we need to show them. In fact, 10% of my
cases have high visit utilization and low functionals.”

Breaking
down the communication silos within an agency — such as between the clinical
team, financial team and coding team — is critical for PDGM success. Agencies
must find the right key performance indicators (KPI) and make holistic
decisions about care.

“The
importance of having a certified coder, a certified oasis reviewer, and then
having an agency to review behind your coders to ensure that you’re not leaving
some opportunities on the table — it’s a must,” Griffin says.

Simione Healthcare Consultants brings a
comprehensive suite of consulting and outsourced services for billing, coding
and OASIS review, and QAPI with Home Health Solutions, a Simione Coding
Company, to help agencies reduce cost, improve quality, and facilitate revenue
capture. Call 844.293.1530 for a consult or quote, or https://www.simione.com/coding-oasis-review