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PDGM Updates

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’ Home Health solution.

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




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.

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 tabListsUsers. 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

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’ Home Health solution.

Referral Tab

Selecting a face-to-face encounter option is now required in the Home Health solution. 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.

Updated on 5/23/2019