Software and Services for Home Health, Hospice and Healthcare Facilities

HealthWare is PDGM Ready!

12/17/2019 HealthWare Financial 3 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.


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.

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