Serving the home health, home care and hospice industry since 1999.

by Darcey Trescone, RN, BSN

EMR vendors in the home health space are already heavily involved in deciphering the regulations published to date for the new Patient Driven Groupings Model, set to change the way home health providers operate as of January 1, 2020. Vendors understand this shift in Medicare's reimbursement policy will require a host of specific changes in their technology in order to accommodate workflows that better support their clients. But how much new software coding will be required, and will most EMR vendors be ready in time? We talked to several of them to find out.

PDGM represents a major change to the home health reimbursement model, PPS, which has been in place for 20 years. CMS wants HHAs to focus on providing appropriate care, based on each patient's diagnosis, and on improving outcomes. This seems simple enough, but with these regulatory changes come higher scrutiny on clinical documentation, appropriate interventions, and goal achievement, with an increased emphasis on risk management and achieving the best clinical outcomes.

With PDGM, clinical groupings and comorbidity adjustments will be based on the diagnoses on the claim, and no longer on the OASIS assessment. It is expected that CMS will be monitoring data submitted by referral sources prior to a home health episode, plus the OASIS data submitted by the HHA, looking for consistency with the claims.

"With PDGM it has been different," Carolyn Dean, Regulations Compliance Manager for Brightree told us. "CMS is working closely with technology vendors to answer questions and provide clarifications. This is the first time CMS has released technical specifications eleven months prior to the required change to help the industry get prepared."

Impact of PDGM on providers

The larger impact of PDGM lies in the changes it will bring about in home health providers' internal operational processes. They will need to focus on documentation timeliness and accuracy, resource utilization management, and monitoring for patient risks and outcomes. All these items will have a direct and/or indirect impact on reimbursement levels and revenue.

Billing will need to occur every thirty days versus the current 60-day period. This means the initial RAP and final claim will occur over a shorter time span than they do now, but OASIS documentation timing remains the same. Unless there is a significant change in condition that impacts why the patient is receiving home health services, the second RAP submitted after day 31 should contain similar information to the initial RAP or SOC. If there is a change in condition, CMS's expectations are that the second RAP submitted after day 31 reflect that change, with both supporting OASIS documentation and orders that reflect care is coordinated with the certifying physician.

The requirements to submit the Final Claim remain the same. Agencies must have a completed and successfully transmitted OASIS assessment, compliant face-to-face certification, signed and dated orders, and a signed and dated plan of care, all of which must be consistent with what has been submitted on the claim. Another complicating change is that agencies will be able to submit up to 25 diagnosis codes on a claim, compared to the six diagnosis codes on the OASIS today. 

Impact of PDGM on vendors

EMR vendors are actively preparing to accommodate the above changes with systems to facilitate claim timeliness, documentation collection, order tracking, and changes to diagnosis codes that will be acceptable to CMS. This is how Homecare Homebase SVP of Product Management Neal Reizer sees it:

"To some degree, PDGM will call into focus the operating efficiencies that agencies do and don’t have. The 30-day timeframe is going to force timeliness of many areas such as: referral management, documentation, quality review process, order management, document management, billing. Core workflows are really going to have to be examined, as well as the relationship with your referral sources. Referral sources that are not timely in communication, document return or accuracy in the referring diagnosis will need to be educated on the impact to home health under PDGM. If you are a provider producing good outcomes for your patients, you will likely do well under PDGM, but all agencies should be evaluating for efficiencies and accuracy in what they are doing regardless."  

Every software vendor spokesperson we talked with agreed that documentation, coding, care planning and care coordination are key best practice clinical strategies that agencies will need to review if they expect to survive reimbursement changes. Revenue will be impacted by diagnosis assignment, coding and OASIS data collection, and contract auditors will be on the lookout for diagnosis codes moved around for payment enhancement rather than clinical reasons. Well planned care coordination and case management strategies can assist in managing expenses around visit utilization, LUPA risks, and appropriate utilization of therapy services.

Chris Taylor, Vice President of Sales for KanTime Technologies Inc., told us, "From an industry standpoint, agencies need to be pushing their vendor, looking for solutions and asking the hard questions internally and to the vendor. An EMR is the life source of how an agency operates. If it fails due to missing functionality or misuse, it can bring an agency to its knees. Agencies under scrutiny for documentation or concerned about their documentation accuracy need to work with the various technology partners within their EMR's ecosystem. There are ancillary technologies that many of the EMR vendors partner with for better document management and clinical compliance to enhance the overall EMR offering." 

EMR vendors must help prepare customers

As we interviewed some of the top software vendors in the home health industry, we learned there is a lot of preparation and planning taking place to ensure their customers are ready to meet the demands of PDGM. We heard from two Brightree department managers on this question.

"We are treating PDGM as its own project and have internal and external (customer facing) plans taking place. Internally we have been reviewing the regulations with our current solutions as a team and have outlined workflow design that incorporates all components of PDGM. Externally we are organizing customer panels to capture feedback on our PDGM designs and how these designs will support the operational processes within the Brightree home health agency." --Jessica Rockne, Product Manager, Revenue Cycle/PDGM Project Manager.

"In addition, we will be releasing a tool for customers to see how their current episodes will look under PDGM and will provide a sandbox environment for Brightree customers to familiarize themselves with workflow and new functionality for PDGM. We are working to help our customers transition successfully in the PDGM environment." --Carolyn Dean, Regulations Compliance Manager. 

All of the software vendors we spoke with are confident that they will be prepared well in advance of the January 1, 2020 deadline. Again from Chris Taylor:

"KanTime is highly configurable and many of the PDGM changes we have solutions for. For example, the 30-day billing period. 25 diagnoses on the OASIS and configurable rules around payer source documentation and collection requirements we already have. Our focus is on our customers' internal operational process and ensuring they are in line with the design of the system to gain the greatest efficiencies. We are rolling out a 'white glove' service to our customers with dedicated resources to help them evaluate their internal processes alongside utilization of our system. We know PDGM is more than just a software update and we are working with our customers to ensure they understand this as well.

"KanTime customers are benefiting from the ecosystem of business partners we have in place. Our relationship with OperaCare provides KanTime customers with real-time information regarding their current clinical documentation, and potential risks they face, to help them better prepare for PDGM. It's like buying a car that requires premium gas and expecting it to run optimally on regular unleaded. PDGM requires extra care and effort to ensure your business processes align with your EMR technology design. A home health agency EMR is most efficient when optimized with the right business partners and the right internal agency processes."

It is critically important as an industry that we learn the new rules and make necessary changes well in advance of the PDGM deadline. As a speaker for NAHC's PDGM National Summits that have been conducted across the country, Neal Reizer of Homecare Homebase understands this all too well.

"PDGM deadlines will cause action. We know there is still uncertainty and interpretation of the regulations occurring, but no one should be ignoring that how we practice today needs to change. HCHB has been working to get our customers accurate interpretation of the regulations all along. Working closely with industry experts, we are already showing prototypes of solutions to gain efficiencies with handling questionable encounters and workflow changes across the agency. We produced an analysis last year for each of our customers to show how they would fair under PDGM. Our customers are pushing the envelope on payment model delivery types and asking the hard questions because they are engaged with us. As a vendor, this allows us to leverage the expertise of all of our customers, including large national providers of home health services."

The home health EMR vendors are heavily entrenched with PDGM at a national level and are working diligently with their customer base. The underlying theme in vendor messaging is that they want to ensure the technology they are providing adequately maps to the workflow processes our industry needs under PDGM. Home health providers should be working alongside their technology providers in these efforts to ensure the greatest efficiencies and success is achieved with PDGM.

Darcey Trescone is a Healthcare IS and Business Development Consultant in the Post-Acute Healthcare Market with a strong background working with both providers and vendors specific to Home Care and Hospice. She has worked as a home health nurse and held senior operational, product management and business development positions with various post-acute software firms, where her responsibilities included new and existing market penetration, customer retention and oversight of teams across the U.S., Canada and Australia. She can be reached at


©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.