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