We acknowledge it is extremely difficult to measure coding accuracy. It seems that the common method used by most agencies is to code the file, submit the claim, and if the claim is accepted then they assume it to be accurate. This is an oversimplified method of measurement as there is no way of measuring how much money may have been left on the table as a result of less accurate codes.
As a basis for measuring the impact of our services (or accuracy) we perform a pre-audit calculation to determine the billable value of the OASIS as it was originally delivered to HCA. Following a thorough review of the patient chart and OASIS, we make suggested coding corrections and OASIS recommendations. A post-audit calculation is then performed. This new calculation takes into account our suggested changes to the OASIS. The dollar difference between the pre and post-audit calculations is how we measure the impact of improved accuracy. This helps insure that you are getting paid the appropriate amount of revenue for each individual patient.
We charge a flat rate of $60 per OASIS file, with a small annual cost of living increase. This includes all ICD-10 coding and OASIS recommendations. An OASIS audit report is provided for each patient file. This also comes with a PDGM value calculator with the LUPA threshold for each 30 day period in the 60 day episode. Coding only files, like commercial insurance where no OASIS was gathered, and hospice files have a flat rate of $40 per file. We can even build the POC in your EMR system if you like for an additional $25, saving your staff lots of precious time, presuming your EMR is set up to generate the POC. Volume discounts are available.
Home Care Answers employs reviewers from all across the country. They are all remote employees and have taken precautions so that we remain available to support agencies.
Our employees are safe and healthy. We have safe measures and availability to handle agency OASIS Review and diagnosis coding. We can provide support so that HHA can focus all resources on treating and addressing COVID 19 and patients as normal. We won't shut down and will continue operations as normal.
We are monitoring regulatory conditions to keep our agency partners informed of any changes and CMS communication.
We differ from our competitors in 3 distinct areas: Our superior OASIS & coding knowledge and experience, our proven review process, and our exceptional track record of results (financial, outcome, and compliance).
Our strategy relies on superior human clinical judgment rather than software. Our reviewers are licensed Registered Nurses with certified coding and OASIS credentials. The level of accuracy and specificity of our coding and OASIS recommendations insure your agency receives maximum reimbursement for services rendered. Home Care Answers’ clients experience a significant increase in revenue based on improved accuracy for each OASIS episode. ADR denials are significantly reduced for our clients through accurate coding and OASIS and improved documentation.
Home Care Answers has developed its own PDGM calculator that provides the reimbursement value of each 30 day period in the 60 day episode along with the LUPA threshold for each period. You get to see what each patient is "worth" and how many visits are required to receive full reimbursement, provided our suggested changes are accepted by the clinician- which has the final say always.
Home Care Answers provides coding and OASIS audit services to home health and hospice agencies. Our goal is to elevate the level of accuracy and effectiveness of ICD-10 coding and OASIS answers to insure compliance and proper reimbursement for our clients. We use our proprietary technology, internally build PDGM Calculator, and best-in-the-industry reviewers to review OASIS, provide PDGM optimized diagnosis coding, and show results in an easy to read report that displays all necessary data. This includes pre/post audit financial gains (or loss if applicable), The early/late episode 30 day reimbursement for each 30 day period, and LUPA threshold for each period also.
We also provide Full QA Audit with cases like ADR style audit. We have the full suite of services to make sure OASIS and Diagnosis Coding are correct and optimized.
We offer OASIS review and coding services for Home Health and Hospice agencies.
We have been in business since 2000. OASIS audit and coding has been our exclusive business since the beginning.
We review the following documentation in order to get a comprehensive picture of the patient’s condition:
Home Care Answers is 100% HIPAA Compliant due to our Agency Portal. With the Agency Portal, no protected healthcare information needs to be emailed anywhere. Everything from initial requests to final individual reports can be completely handled in the Agency Portal.
PDGM stands for Patient Driven Grouping Model and is a value based reimbursement model that uses information from OASIS and ICD-10 diagnosis codes to determine the reimbursement amount that each patient will require to provide a positive outcome. Therapy visits are no longer part of the reimbursement model, so having OASIS and ICD-10 diagnosis codes be correct is absolutely essential.
CMS uses the information from OASIS assessment from M1800 questions, M1033, and the referral source and the primary diagnosis code in M1021 to determine the reimbursement rate. From that information, PDGM puts each patient into 6 clinical groups, and one of those groups is broken into another 6 groups. One group is broken up into 6 sub groups. Those groups are Musculoskelatal Rehabilitation, Neuro/Stroke Rehabilitation, Wounds, Complex Nursing Interventions, Behavioral Health, and Medication Management, Teaching, and Assessment (broken into 6 groups). The information form the Home Health Resource Group (HHRG). There are 432 possible case mix adjustment payment groups.
PDGM 2020 and ICD 10
CMS has always wanted HHA to document and code with the highest level of specificity. For a long time, HHAs would use symptom codes as primary diagnoses such as Mucsle Weakness, Gait Abnormality, etc. as a primary diagnosis. However, these diagnosis codes did not show the underlying cause of the weakness. PDGM requires that HHA provide the underlying cause with the highest level of specificity possible. Documentation is key to success in PDGM.
List of diagnosis for PDGM
CMS has released several great resources for HHA to use. One of the biggest questions is finding a list of acceptable primary diagnosis codes for PDGM.
Here are some helpful links from CMS. You can download the PDGM grouper tool and look on the 3rd tab of the spreadsheet for the comprehensive list.
CMS has given a summary of PDGM here.
PDGM Grouper Tool
Home Care Answers has built a grouper tool that shows what the reimbursement rate for each patient will be, what clinical grouping, and the associated LUPA threshold for each patient. This is given for each patient in the report we send.
Home Health Agencies (HHA) that have relied on therapy utilization as the primary means for revenue will likely be negatively impacted. With PDGM removing therapy utilization as a factor into the reimbursement calculation, therapy utilization needs to be included and accounted for in the care plan. CMS has a good idea of costs involved with home health and has used the data HHAs have given it to determine reimbursement rates. By breaking the 60 day episode into two 30 day periods, CMS and agencies need to continue to show medical necessity to continue care. Many agencies under PPS were handling ortho patients and discharging in 28 days but receiving 60 day reimbursement. PDGM addresses and corrects that issue. PDGM provides the HHA the reimbursement value based on the condition of the patient and the anticipated cost to provide care for that patient. Wound patients cost HHA a lot of time and resources, so wound is reimbursed higher.
Cost management is a big factor in the impact HHA will have. In our results, many agencies that can reasonably get patients the full episode are seeing the same or slightly improved revenue.
One area that is important for HHA is cost control. Agencies must manage and control costs of the care plan for each patient. By optimizing cost control and care plan, and maximizing reimbursement through correct OASIS and coding, agencies are thriving. Home Care Answers provides the LUPA threshold and reimbursement for each patient on each report we provide. These reports are essential in the care plan.
PDGM Therapy Impact
Many therapists have been concerned with the financial impact of PDGM. PDGM gives HHA a total amount of reimbursement for each patient. HHA need to provide the care the patient needs including therapies (PT, OT, ST), skilled nursing, supplies, and education. There are more inputs than that, but those are the primary cost imputs. Therapy aids are a good way to control costs. Maybe an aide can make a visit to monitor and document vs the therapist. Therapist inherently cost more than an aide.
Here is a good link addressing therapy impact.
Home Care Answers began planning for PDGM as soon as it was announced. We developed, tested, and released a PDGM Calculator in July of 2019, along with LUPA threshold for each 30 day period in the 60 day episode. This is shown on an easy to read report on every chart.
Further, we have always coded to the highest level of specificity possible. Our aim is to get things correct. When things are correct (OASIS and Coding) then revenue, compliance, and Star Ratings Follow.
No. The suggestions provided by scrubber software are numerous and too vague to be of any real benefit. We use human clinical judgment supported by a superior knowledge of OASIS rules and definitions as established by CMS. Understanding these rules enables us to confidently and assertively apply them to each OASIS episode as we seek to improve accuracy and legitimately maximize revenue.
In our view, scubbers and AI ensure an an answer is completed for OASIS and there are no unresolved errors. However, AI does not look at the big picture and take into account the whole condition of the patient. Scrubbers ensure of no rejectable errors. We ensure that OASIS questions are MOST correct.
If an Agency has a scrubbing software such as SHP, we will run SHP and resolve potential errors.
Yes. We make specific recommendations to the treating clinician on how to more accurately answer OASIS questions. Each recommendation is accompanied by a specific explanation that supports the recommended change. See example report
We provide a one-business day turnaround for OASIS auditing and coding.
Yes. However, we do not suggest changes to this question for the purpose of increasing revenue. We understand Medicare rules well enough to know that manipulating the number of therapy visits for financial gain is short sighted as reimbursement adjustments will be made at the end of care based on actual supported therapy visits. We review all professional evaluations and documentation available and will only suggest adjustments to the service questions when: 1) the documentation does not support the number of therapy visits designated by the clinician, or 2) when the number of therapy visits designated by the clinician is either insufficient or significantly over-estimated relative to the condition of the patient (as supported by clinical documentation), or 3) the number of therapy visits listed in M2250 clearly does not match with the therapy evaluation.
All of our reviewers are either currently HCS-D and COS-C, or HCS-O certified, or will be within 1 year of their employment with Home Care Answers. Those who are not yet certified have 100% internal Quality Assurance by Management that does have those certifications. All of the RN reviewers have multiple years of clinical experience in Home Health.
Yes. We can provide your agency with a variety of reports, such as financials, timeliness, executive summaries, etc. We are regularly developing additional specific clinical reports for our client's use as well.
We have executive dashboard that shows a running total of OASIS suggested changes for key OASIS groups, PDGM/ADL Questions, 5 Star Questions, GG Questions, and Overall OASIS questions. This is helpful for QAPI iniativies and training opportunities.
We can track these changes by clinician so we can have individualized training. We can track these changes over time to measure training effectiveness.
Most of the time, star ratings are negatively impacted because of erros in the OASIS at the beginning of the episode. If OASIS is not correct at the beginning of the episode, it is very difficult to get it correct at the end of the episode at discharge.
When Home Care Answers can review OASIS at the beginning of the episode and associated episodes and the discharge OASIS, we will compare with the same perspective.
This gives the agency credit for the great work they're already doing! Most of the time, there is improvement by the patient during the episode, but errors in OASIS prevents the agency from showing the improvement.
Yes. We offer a trial service to allow agencies the opportunity to experience the value they can expect to gain as a result of the coding and audit services we offer. The trial service is merely a sample of the standard services we offer and involves a complete OASIS audit and diagnosis coding of Start of Care (SOC) OASIS files.
The trial service is free. A trial batch typically consists of 5 to 10 Start of Care OASIS files, but can be customized to fit your particular needs.