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HealthWare is PDGM Ready!

12/17/2019 HealthWare Financial 2 Comments


After waiting months for the final documentation and specifications to be released, we are proud to say that we are confident that all our clients are ready for those big changes coming 1/1/2020. With PDGM and OASIS D1 there are a lot of changes that agencies must be ready for and have the tools and processes in place that can handle these changes. At HealthWare, we have worked hard to make sure that you will not only endure PDGM, but prosper with PDGM.

We started out with a simple premise: make it easier for agencies to handle the changes related to PDGM. There are a lot of moving parts and they affect several different areas of the agency’s operations, and HealthWare has worked to provide tools to help with these various areas.

We had a big head start, because HealthWare is already a very mature platform with many great features that will be tremendously useful under PDGM. We also wrote our own PDGM grouper early in 2019 and started integrating it soon thereafter, and then updated it to comply with the final specifications. This was a big help in making sure we had this major capability ready; CMS did not release their grouper until the end of October, not leaving much time for integration and testing. Writing our own grouper also made sure we knew what data was needed and how to handle it to determine the all-important HIPPS code and pricing.

We looked at patient intake/referral and ways we could speed up that process. After analyzing this information, we made various improvements, such as making even fewer fields required initially, which reduced referral input time. We then tied the appropriate data directly to the information needed to get the PDGM episode started, so you can accomplish both with no additional steps. This process can also create any workflow you desire, meaning all departments and/or staff involved can start the next steps in the process.

At the point of care, you can auto-fill more data taken from the referral, with the clinician’s review and approval, thereby speeding data entry and helping to get documentation completed more quickly. This includes things such as: diagnosis codes, certification dates, physician, etc. More validation related to PDGM is also done at the point of care helping to make sure your data is ready to bill faster than ever before.

Of course, we also put in a lot of PDGM-specific validation at various points along the process. Things like checking to make sure the primary diagnosis is eligible for billing, making sure users know if there are one or more co-morbidity diagnosis codes, validating the OASIS to make sure it is properly scored, and more.

Overall process flow for each patient and episode is critical to thrive under PDGM, so we have improved our workflow capabilities to help agencies be successful with PDGM. New patient tracking features, event triggers, and alerts are all part of HealthWare’s PDGM capabilities. This helps you move the patient from intake to RAP as smoothly and quickly as possible.

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Of course, there are also powerful features for billing PDGM. With 30-day payment periods, the efficient handling of billing and claims is even more vital than it was under PPS.

  • Document Tracking and billing are linked together, automatically releasing bills when the proper documentation is complete, and signatures collected. This works via the physician portal, bar code scanned documents, and more.
  • Simple processing of recodes that automatically identifies payment episodes that have had changes which could trigger a recode. You can check to see the effects of the recode on the payment episode, and if you want, you can recode and adjust A/R to reflect what you expect to receive with the final payment.
  • Validation of all data required to complete the claim as well as making sure you cannot enter invalid combinations. For example, the source of admission is community and yet you entered a hospital discharge date; or validating that the institutional discharge was within 14 days.
  • Automatic handling of Occurrence codes for final claims, so they will be set properly. For example, Occurrence code 50 will be set as M0090, Occurrence code 61 will be set based on hospital discharge date, and occurrence code 62 will be set based on another discharge date.
  • LUPA threshold handling per HIPPS code.
  • Additional ANSI claim validation.
  • PDGM claims continue to support Review Choice Demonstration (RCD) and Unique Tracking Number (UTN) requirements.

HealthWare’s PDGM Insights tool gives you extremely powerful information about the episode, payment, costs, and more. Get details on the eligibility of the primary diagnosis and any co-morbidities of the secondaries. See the effects of all episode timings, admission sources, comorbidities, and impairment levels. It also shows you the effects of secondary diagnoses becoming primary. More importantly, it shows—based on visits, both completed and scheduled—what the projected profit or loss is for each payment episode.

HealthWare also provides billing services for their clients, so it was important not just for our clients, but also for our own in-house services, that using HealthWare with PDGM be as efficient as possible and enable scenarios not possible with other solutions.

Diagnosis Codes under PDGM

10/24/2019 HealthWare Financial 6 Comments
Diagnosis codes under PDGM

There are several important changes regarding Diagnosis Codes that you need to be aware of and start preparing for under the soon-to-be-implemented Patient Driven Groupings Model (PDGM).


In short, you need to make sure the primary diagnosis code submitted on your claim is payable under PDGM and that you submit all eligible secondary diagnosis codes, up to 24, so that you can take advantage of any comorbidity adjustments that might apply.


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HealthWare Physician Portal

9/21/2019 HealthWare Clinical 3 Comments


Document control has never been easier or faster than with HealthWare’s Physician’s Portal. With this web-based tool, physicians you work with can handle reviewing and signing documents digitally, and it’s available to them anywhere they have internet access. This can include interim orders, POCs, and face to face. The portal also tracks the physicians time spent reviewing each patient’s documents and chart and provides the physician a report at the end of each month that can be used for oversight billing. This is a great selling feature to convince your physicians to adopt electronic signing. 

Obviously with HIPAA, security is paramount, so HealthWare uses three-part authentication for the portal. To access the portal, all you do is send the physician your secure link and access code that is unique to your agency. The physician opens the link and logs into the portal where they will have access to documents needing their signatures as well as their patient’s charts.

  • The homecare organization maintains the physician’s username and can reset their password if needed.

  • Each physician is assigned a username and temporary password.

  • On first access to the portal, the physician will be asked to change their password to a new password only they will have access too.

Summary of CMS August PDGM Call

9/5/2019 HealthWare Clinical 0 Comments

Executive Summary Horizontal Wide 1488 x 432

On August 21, 2019 CMS had a Home Health Patient Driven Groupings Model Operational Issues Call. In general, it covered much of what we already know and focused specifically on the claims submission and claims processing as a result of PDGM. It is important to note that many things stay the same under PDGM, but that there are some important changes.

Summing Up

  • Payments are calculated based on 8 OASIS items, Diagnoses, Period and Source of Admission.
  • Diagnosis codes are taken from the claim, not the OASIS.
  • Claims not OASIS are the source of payment diagnosis codes.
  • You can submit any valid HIPPS code.
  • Medicare will use data from its systems to calculate the Final HIPPS and episode payment.
  • You submit claims every 30 days.
  • You will use Occurrence code 50 to report Assessment Date.
  • You will use Occurrence codes 61 or 62 to report institutional admission sources, you must use only one, and if you use neither, the claim will be reported as a community admission source. Medicare does not use OASIS M1000 for admission source.
  • If you submit the claim with a community payment group:
  • If Medicare finds an inpatient claim with a “Through” date within 14 days of the home health “From” date they will group it into the institutional payment group.
  • If Medicare does not find an inpatient claim with a “Through” date within 14 days of the home health “From” date they will group it into the community payment group.
  • If an adjustment is made to change to an institutional payment group, it will be identified on the remittance advice.
  • If you submit a claim reflecting an institutional payment group, Medicare will not adjust to community if no inpatient claim is found after the timely filing period closes. This is because the inpatient stay may have been in a non-Medicare facility.
  • Medicare will use prior home health claim data to determine the early or late period timing.
  • If a prior claim is found within 60 days before the “From” date Medicare will group the claim as Early, otherwise, it will group it as late.
  • The transition from PPS to PDGM will treat episodes that being on or before 12/31/2019 as PPS and anything on or after 1/1/2020 as PDGM.

More Details in Case You Are Interested

You submit your OASIS very similar to how it has always been done.

One thing that is very different, the HIPPS code used when submitting the OASIS only has to be a valid HIPPS code, it does not have to be calculated using a grouper. The reason is that under PDGM you need claims data to calculate a HIPPS code. This HIPPS code will be used to calculate the split percentage payment so you really want it to be as accurate as you can get it to reflect properly in your AR, so you need to work with your software vendor to make sure you can do so.

You submit the RAP and will receive a split percentage payment.

You now provide 30 days of service and then submit a Final claim with the same HIPPS code used on the RAP, along with service line item details.

The Medicare system will combine OASIS and claim data and use their grouper to produce a HIPPS code, and that will be used for payment. This will also consider claims history and inpatient discharge information to determine period and admission source when calculating the HIPPS code.

The HIPPS code that Medicare will use in its calculation is made up of the admission source, which it will look at claims data to find previous inpatient stays, period timing, diagnoses and functional impairment level based on the values of 8 OASIS items.

  • Each 30-day period is classified into one of two admission source categories, community or institutional. This depends on what healthcare setting was utilized in the 14 days prior to home health admission.
  • The first 30-day period is classified as early. All subsequent 30-day periods in the sequence (second or later) are classified as late.
  • In addition to the primary diagnosis, PDGM includes a comorbidity adjustment based on the secondary diagnoses. You can receive no adjustment, a low adjustment or a high adjustment.
  • Low comorbidity adjustment: A secondary diagnosis is associated with higher resource use.
  • High comorbidity adjustment: Two or more secondary diagnoses are associated with higher resource use when both are reported together compared to if they were reported separately.
  • Functional impairment level is determined by 8 OASIS items, M1800, M1810, M1820, M1830, M1840, M1850, M1860 and M1033.

So, the RAP is paid based on the HIPPS code you submit on the RAP, and the Final is paid based on the HIPPS code calculated by Medicare. If your RAP was submitted with a poorly calculated HIPPS code, your final payment may vary greatly from your projected payment.