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

  • The report looks at the expected payment amounts for episodes within the selected year chosen for patients with an OASIS Discharge, Recertification, Resumption of Care, Transfer to Inpatient Facility, or Transfer Discharge.
  • The report does not include sequestration, outliers, or Value-Based Purchasing adjustments.
  • Information is available to review for 2017 and 2018. Information for 2019 includes financial data as of the last updated date, which is adjusted at the beginning of each month.

Questionable Episodes

The Questionable Encounter Code metric:

  • Includes the number of affected episodes within the total number of episodes the agency has billed for the reporting period.
  • Includes the percentage and number of questionable episodes where primary diagnosis codes that are not groupable under PDGM were used.
  • Identifies how much revenue was billed under the current PPS billing system using questionable primary diagnosis codes and the dollar amount reflecting codes that will not be billable in January 2020 under PDGM.

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

  • ICD-10 codes that are symptom codes, R-codes, and codes with a description containing the phrase “unspecified” fall into the category of questionable episodes.
  • See the PDGM Modeling Tool (Home tab ➜ PDGM Modeling Tool) to learn more about the PDGM diagnosis impact upon billing.
  • The Home Health solution gives a warning when questionable codes are entered into the system at intake and on completion of the OASIS assessment.

Full Episode Pay for DC in 30 Days

The Full Episode Pay for DC in 30 Days metric:

  • Identifies episodes where the patient was discharged within 30 days, but the agency was paid for the entire 60-day episode.
  • Includes the number of affected episodes within the total number of episodes the agency has billed for the reporting period.
  • Includes the percentage of PPS episodes and the amount or revenue billed.
  • The PDGM projected revenue is calculated based upon the new 30-day payment episode as the full 60-day payment episode will not be paid under PDGM.
  • The gain/loss of patients discharged while the agency received full payment for the 60-day episode, and the percent of change in revenue, enables agencies to evaluate financial impact.
  • Under PDGM, if a patient is discharged from care during the first 30-day payment period, there is no payment for the second pay period.
  • If the number of visits provided in the first 30 days meets the LUPA threshold for that period, a full payment is provided for the first payment period.
  • For episodes that begin with a Start of Care, the payment will be  approximately 85% of what it would have been paid for the full episode under PPS.
  • For episodes that begin with a Recertification, the payment for the first payment period will be about half of what would have been paid under PPS for equal work.

Episode Includes 30-Day LUPA Rule

  • LUPAs under PDGM are more vital than before.
  • LUPA rates vary and are based upon 30-day pay periods (versus 60-day pay periods under PPS).
  • Under PDGM, each of the 436 HHRGs has an assigned LUPA threshold.
  • The value of these thresholds varies from 2 to 6 visits.
  • If the visits provided in a 30-day payment period do not meet the threshold, payment will be based on a per visit rate (no change from PPS).
  • One or both payment periods can be paid on a per visit basis. The percentage of episodes with a LUPA portion may be higher than experienced under PPS.
  • Overall, Axxess clients have an average of 14% of episodes containing at least one LUPA payment period. In comparison, about 9% of the episodes were treated as LUPAs under PDGM.
  • The Home Health solution identifies LUPAs for each 30-day payment period in the PDGM Case-Mix Analysis Report.

Full Pay for 60 Days

  • The Full Pay for 60 Days metric identifies episodes where the patient was discharged by the end of the 60-day payment episode and the full episode was paid.
  • Generally, this happens with about half of the episodes provided by an agency and the sum of the payments for the two payment periods is about 15% higher than the payment received under PPS.

PDGM Clinical Groupings

  • This section identifies diagnosis types commonly used by your agency and the corresponding clinical groupings.
  • Questionable encounter codes are not listed in the Clinical Groupings, since they are not groupable.

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