PDGM and My Diagnosis List

In News, OASIS, Online Training, PDGM by Sarah Bacon8 Comments

A question that we all have pondered at some time over the last few months…How are those diagnoses going to get on that claim? What do they mean when they say the diagnoses don’t come from the OASIS? What if a new diagnosis is communicated to us in the middle of a 30-day period and a new OASIS is not completed, and furthermore it doesn’t need to be completed?

First, you need to understand how the claims system works now. The “grouper” is in the billing software and captures the scores/diagnoses groups from all the OASIS payment items. The grouper calculates a HIPPS code and transmits that HIPPS code and an OASIS treatment authorization code to CMS contractors (e.g., Palmetto) and we are paid our RAP based on that HIPPS code. The treatment authorization code includes how we answered every OASIS payment item. At the end of the 60-day episode, we send a claim with the same HIPPS code (the last character of the HIPPS may be different if you provided supplies.) CMS has edits in the claims system to adjust payment based on claims data whether the episode is early or late and the number of therapy visits that are on the claim.

Currently the HIPPS code on the RAP has to match the HIPPS code on the claim. The diagnoses have to match between the OASIS and the claim.

With PDGM, the “grouper” is in the CMS claims system, not in the billing software (although most software will likely include the grouper so agencies have an idea how much they will receive for the payment period). The HIPPS code on the RAP just needs to be a valid HIPPS code. The grouper will capture only the functional score from the last OASIS that was transmitted to the iQIES. The grouper will capture no other information from the OASIS assessment itself. The scores for the functional items will then be combined with claims data (diagnoses, early/late, and source of admission) to calculate a HIPPS code.

So, what about those diagnoses? Most, but not all, home health software systems take the diagnoses list from the OASIS comprehensive assessment and place them on the Plan of Care and the claim. If your present software takes as many as 25 total diagnoses from the assessment and places them on the claim, you are set as far as getting the diagnoses to the claim. Ensure that your software does that with the SOC, the recertification, the other follow-up and the ROC. These are the OASIS assessments that may be used to update the functional scores in the OASIS and therefore diagnoses on the claim. Any updates that result in a ROC or Other Follow-Up will be used on the next 30 day RAP/claim.

What about the new diagnosis that got verified by the physician sometime in the middle of the 30 day payment period? Or the diagnosis that exacerbated and needs to be moved up in the list? There needs to be some way that for the current 30 day claim to be updated or the next 30 day list to get updated. It is incorrect to think you will need to another Other-Follow Up in this case. Having to complete another OASIS just to get an updated diagnosis list is a horrific administrative burden.

One such possibility is an active diagnosis list. The diagnoses would “match” what was on the current claim and any updates can be made to this list. For example, an established diagnosis of Parkinson’s is finally verified and so is placed around #9. The COPD that was #13 on the list is exacerbated with new meds and increased oxygen. COPD is not the primary reason for care but is moved to #3. Now, you need to decide how this is going to work. How will this list be updated? What communication is needed? Who will update the list? The coder? How will these changes be communicated to the biller so that the claim can be updated?

  1. Does your software have the capability to take at least 25 diagnoses to the claim?
  2. Does your software have the capability to take at least 25 diagnoses to the claim from the Other Follow Up assessment?
  3. What is the capability for updating the diagnoses list without having to do a comprehensive assessment? Remember an Other Follow Up is only required when the patient has a major improvement or deterioration that was not foreseen.

Lisa is producing a new PDGM series. The first module of this series is a 4-hour online course that includes an overview of PDGM. Other modules in the series will include a deep dive into the Clinical Grouper and comorbidities, a look at your LUPAs, improving your functional scores, and OASIS D1.

To learn more about the PDGM series, click here.


  1. Our home care is merging with another home care agency. We are discharging our patients from our current agency and re-admitting them into the new home care agency. Our question is “do we enter the onset date and exacerbation dates on the new start of care? ” Thank you for the clarification.

  2. Tricare is following PDGM guidelines, but is still requiring the treatment authorization on the claims. My grouping software does produce a treatment authorization. Is this possible under PDGM?

    1. Author

      If a Commercial carrier is following PDGM rules then a Treatment Authorization Code is not required. But TriCare could be talking about their Authorization Code for the services that they Authorized. It goes in the same place on the claim as the TAC Code.

  3. the pdgm tool you mentioned in the webinar nov 17–where can i locat this on your web site?

    thanks you

    1. Author

      The tool is not available yet, however we are expecting to launch it any day now. Once the tool is live on our website, we will send out an announcement via email & Facebook.

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