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PDGM System Features

 

PDGM Case-Mix Analysis


The PDGM Case-Mix Analysis compares your agency’s revenue for a single patient under the current Prospective Payment System (PPS) to your projected revenue under the Patient-Driven Groupings Model (PDGM). Once an OASIS is completed, view the PDGM Case-Mix Analysis by selecting the green dollar sign symbol next to the completed OASIS assessment in the Schedule Center.

 

 

Permission to view this feature is given in the Permissions tab when adding or editing a user. To give a user this permission, select the Admin tab> Lists > Users. In the Users list, find the appropriate user and select Edit. Select the Permissions tab on the left-side menu. Scroll to the Billing section on the right side of the Permissions screen, and select View HHRG Calculations. Click Save. The user will then be able to view the PDGM Case-Mix Analysis in the Schedule Center.

 

 

The analysis will enable you to see HHRG scores under PPS and PDGM and prepare for accurate coding, LUPA thresholds for each 30-day payment period, and proper visit utilization under PDGM.

 

 

Click the video below to watch an overview of the PDGM Case-Mix Analysis feature:

 

 

PDGM Modeling Tool


This interactive training tool is designed to help you learn how different factors generate the payment resource groupers under PDGM.

 

The tool is not tied to any patient, so each variable that impacts payment can be adjusted to give you targeted insights into how you can collect maximum reimbursement under PDGM.

 

 

Accessing the PDGM Modeling Tool: All users have access to the modeling tool under the Home or Help tab, and when editing or creating a patient in Axxess AgencyCore.

 

From the Home tab:

 

 

From the Help tab:

 

 

From editing/creating a patient:

 

 

Admission Source and Timing 

Payment periods are grouped by admission source (community versus institutional) and period timing (early versus late). Select one of the following to indicate the admission source and the timing of the admission:

 

 

Admission Source

Institutional:

Community:

 

Timing

Sequence of home health periods: Periods with no more than 60 days between the end of one period and the start of the next period (no change from current definition).

 

Clinical Groupings (From Principal Diagnosis Reported on Claim)

 

 

Clinical groups are intended to reflect the primary reason for home health services

If a diagnosis code is used that does not fall into a clinical group (e.g., R-symptom codes or unspecified codes), the claim is not payable and returned to the provider for more definitive coding. Axxess warns agencies to not enter unpayable codes through out the software (starting at patient intake).

 

Enter a primary diagnosis. If the diagnosis is groupable, then a clinical grouping will be highlighted. If a questionable encounter code is entered, then a message will appear stating the code is not groupable.

 

Comorbidity Adjustment (From Secondary Diagnoses Reported on Claim)

A comorbidity is defined as a medical condition coexisting in addition to a principal diagnosis. Comorbidity is tied to poorer health outcomes, more complex medical need and management, and higher care costs.

 

PDGM includes a comorbidity adjustment category based on the presence of secondary diagnoses.

 

A 30-day period may receive:

 

To obtain the comorbidity adjustment, enter secondary diagnoses. When a secondary diagnosis that represents a comorbidity adjustment is entered, then a low or high indicator will appear.

 

 

Functional Impairment Level (From OASIS)

Steps for Creating the Functional Impairment Levels

  1. Determine points for response groups. Resource use is regressed on the seven OASIS items (along with other covariates from each of the PDGM groups). Regression coefficients determine the number of points. Points reflect relative resource group (high intensity, greater number of points).
  2. Calculate the functional score. For each 30-day period, points are summed to determine an overall functional score.
  3. Assign functional impairment level using score. Within each PDGM diagnosis grouping, periods are split into thirds and assigned to a low, medium, or high functional impairment group.

Select one of the following functional impairment levels to simulate a low, medium, or high PDGM diagnosis grouping HHRG.

 

 

Home Health Resource Group (HHRG)

The Home Health Resource Group is comprised of five main case-mix variables:

A 30-day period is grouped into one subcategory in each color category. This results in 432 possible case-mix adjusted payment groups into which a 30-day period can be placed:

 

 

To select other responses for a new case-mix, simply start entering different information for each section.

 

Click the video below to watch an overview of the PDGM Modeling Tool:

 

 

 

PDGM Revenue Impact Analysis


Using historical OASIS and visit information, this analysis assesses the impact of PDGM on revenue, based on past episodes. This data is more accurate than any comparable revenue impact analysis in the industry, since it assesses your data for the last three years and shows questionable encounter codes that will not generate payment under PDGM.

 

 

Accessing the PDGM Revenue Impact Analysis: Users with permission to view financial reporting can find this report under the Home or Reports tab.

 

To give a user this permission, select the Admin tab> Lists > Users. In the Users list, find the appropriate user and select Edit. Select the Permissions tab on the left-side menu. Scroll to the Reporting section of the Permissions screen, and select Access Billing/Financial Reports. Click Save.

 

 

The user will then be able to view the PDGM Revenue Impact Analysis in the following locations.

 

From the Home tab:

 

 

From the Reports tab:

 

 

 

As you review your report, it will be immediately apparent how the questionable primary diagnosis encounter codes (which are not payable under PDGM) will financially impact your business. Preparing for these coding practices will have the greatest impact toward achieving success under PDGM.

 

There are multiple tool tips included in the report to guide you through the information.

 

 

Included Episodes

 

 

 

Questionable Episodes

 

The Questionable Encounter Code metric:

Questionable episodes identify the greatest impact to the business and represent the greatest need for change to be financially successful under PDGM.

 

 

 

Full Episode Pay for DC in 30 Days

 

The Full Episode Pay for DC in 30 Days metric:

 

 

 

Episode Includes 30-Day LUPA Rule

 

 

 

Full Pay for 60 Days

 

 

 

PDGM Clinical Groupings

 

 

Click the video below to watch an overview of the PDGM Revenue Impact Analysis:

 

 

 

Gross Margin Calculator


The Gross Margin Calculator shows your agency’s gross profit and loss so you can adhere to predetermined gross margin percentages and evaluate care and utilization more closely. It assists with financial operations by ensuring the proper steps are taken upfront to encourage accountability and communication between financial and clinical operations.

 

 

All users with access to the Quality Assurance (QA) Center can open the Gross Margin Calculator when reviewing OASIS documentation.

 

The following items are available in the in the Gross Margin Calculator and explained further below:

 

OASIS Episode Information

Average Discipline Cost Per Visit X Number of Visits = Total Cost

(Average discipline cost per visit is identified in Manage Company Information under the Admin tab.)

1) Use the Cost Modeling tool to adjust the number of therapy visits, then update Therapy Visits (M2200) in the OASIS assessment.

2) Update the Clinical and Functional items in the OASIS assessment.

Once the OASIS assessment is updated, the information in the Gross Margin Calculator will automatically update to reflect the changes.

 

Cost Modeling

Frequency X Average Cost Per Discipline + Supplies = Total Cost

The average cost per discipline is pulled from Manage Company Information and should be based on numbers from the agency’s cost report, which includes visit cost plus overhead.

 

Payment Projection

Case-Mix Rate – Total Cost = Expected Payment

 

 

OASIS Case-Mix Analysis

 

Clinical Points:

 

Functional Points: 

 

Non-Routine Supplies (NRS) Points: 

 

 

The table below demonstrates the total points for the corresponding therapy visits and episode that produce the Home Health Resource Group (HHRG):

 

 

Intake Form Updates


During the intake process, alerts notify you instantly if a diagnosis is payable under PDGM, so you know immediately if more information is required to generate a payable code. This system enhancement enables you to decide at intake if a patient is eligible for home health services, and protects your revenue for the care your agency provides.

 

An overview of updates made to the intake forms in preparation for PDGM is provided below:

 

Demographics Tab

Admission Source and Timing have been added to the intake process in preparation for PDGM.  It is vital that this information is entered into the system correctly. This information will be the basis of several reports and PDGM projection tools at intake.

 

The information entered here will flow to the OASIS assessment.

 

Clinical/Diagnoses Tab

Primary Diagnosis is now required in Axxess AgencyCore.

 

Referral Tab

Selecting a face-to-face encounter option is now required in AgencyCore. For insurance types that require a face-to-face encounter visit (e.g., Medicare, Medicaid), the date of the physician encounter is required as a part of the certification statement on the Plan of Care. Two responses are available:

 

 

 

A third response option (N/A) is available when face-to-face documentation is not required by the insurance payer.

 

Tool tips provide additional information and resources for understanding face-to-face regulations.

 

Click the video below to watch an overview of the Intake Form Updates:

 

 

Orders-Driven Scheduling


Orders-driven scheduling enables agencies to optimize operations in the following ways:

 

Set Up Orders-Driven Scheduling 

 

 

 

Functionality

 

Once the features are enabled, all visits will require an order before scheduling. Any new episodes will have calendars that are greyed out, except the first seven days of the episode.

 

 

 

Visits scheduled and performed in the first seven days of the episode will have a frequency warning symbol in the Schedule Center, until the OASIS is approved.

 

 

Once approved, the warning will be replaced with a green check mark symbol (as long as the visit falls within the ordered frequency).

 

Once all visits are scheduled, users can access the Frequency and Duration Summary in the Schedule Center, to quickly determine whether a visit was scheduled according to the ordered frequency.

(Schedule Center > Episode Manager > Frequency and Duration Summary)

 

 

If the user attempts to schedule more than the ordered number of visits for a given frequency, a warning message will instruct the user to complete a new order before scheduling further visits.

 

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