Webinar Recap: PDGM Analysis – Maximizing Revenue and Improving Outcomes

On January 29, 2025, SimiTree hosted an in-depth webinar on PDGM analysis, providing home health agencies with expert insights into maximizing revenue and improving patient outcomes. Led by Emily Hobbs, RN, MHA, BSN, HCS-C, HCS-D, HCS-H, HCS-O, the session covered Face-to-Face (F2F) compliance, coding accuracy, functional scoring, and financial strategies to help agencies thrive under PDGM. We hope you find this blog useful, and don’t hesitate to reach out to us with questions. In the meantime, please enjoy this recap and watch the full webinar or ask for a discounted PDGM analysis session today!

Key Takeaways from the Webinar

1. Face-to-Face (F2F) Compliance in Coding

  • Agencies must ensure they are meeting all requirements of the Face-to-Face regulation for an allowed provider, timing, and components of the actual visit.
  • Telehealth for F2F Visits: While CMS allows telehealth to meet F2F requirements through March 2025, any stricter state-specific provider telehealth policies must be followed for compliance.
  • The Face-to-Face encounter must support the primary reason the patient requires medically necessary, skilled home health services.

2. Selecting the Right Primary Diagnosis for PDGM

  • The primary diagnosis should reflect the condition being treated in the Face-to-Face encounter leading to the Home Health referral.
  • Diagnosis selection directly impacts reimbursement under PDGM. Choosing a less specific or ineligible diagnosis can result in lower reimbursement or claims denial.
  • The admitting clinician must identify the Focus of Care and primary diagnosis.
  • Agencies should conduct routine audits to ensure their ICD-10 coding aligns with the Face-to-Face encounter, OASIS, and Plan of Care.

3. Revenue Impact of Comorbidities & Common ICD-10 Coding Errors

  • Comorbidity adjustments can significantly impact reimbursement—ensuring accurate, allowable secondary diagnoses is key.
  • Common ICD-10 coding errors include:
    • Failing to include all relevant comorbidities that increase case-mix weight.
    • Lack of specificity including laterality, combination codes, and manifestation sequencing.
    • Coding without provider documentation including lack of provider authentication, wound etiology, and resolved conditions.

4. OASIS Functional Scoring & Its Effect on VBP Outcomes

  • The OASIS functional assessment plays a critical role in PDGM scoring and Value-Based Purchasing (VBP) performance.
  • A thorough comprehensive assessment and timely therapy functional assessments are critical components when applying guidance to the OASIS questions.
  • Agencies must ensure that functional scoring accurately identifies the patient’s ability and safety with tasks, not necessarily their performance.
  • Clinicians should avoid the use of “88” (activity not attempted) in the GG sections, following guidance to utilize patient/caregiver report, collaboration, and assessment of similar activities to complete the questions.

5. Evaluating Coding & OASIS Accuracy for Sustained Success

  • Regular coding and OASIS audits help agencies identify trends, prevent revenue loss, and enhance patient care planning.
  • SimiTree Compass allows agencies to assess utilization patterns, track OASIS accuracy, and benchmark visits against industry best practices.

6. Practical Steps to Implement PDGM Analysis Effectively

  • Use data analytics to track trends in visit utilization and diagnosis-related reimbursement changes.
  • Train staff on common coding and OASIS pitfalls to reduce errors.
  • Implement routine internal audits to validate compliance and revenue optimization.

Frequently Asked Questions (FAQs)

💬 Can state policies override CMS regulations for F2F telehealth visits?
No—states cannot override federal regulations but can impose stricter telehealth policies. Always review state telehealth practice acts for compliance.

💬 How does primary diagnosis selection affect PDGM reimbursement?
Choosing an inappropriate or vague primary diagnosis can reduce reimbursement or lead to claims denial. Selecting an eligible, specific diagnosis is essential.

💬 What are the biggest ICD-10 coding mistakes under PDGM?

  • Failing to code all comorbidities that affect reimbursement.
  • Lack of specificity in coding- laterality, 4th-7th characters, combination codes, manifestation sequencing.
  • Incorrect Primary diagnosis.

💬 How does functional scoring impact VBP?
Accurate OASIS scoring at Start of Care allows the agency to show valid progress and improvement made at Discharge.

💬 What benchmarking tools can help agencies analyze PDGM performance?
SimiTree Compass provides customized utilization tracking and visit benchmarking, allowing agencies to adjust care planning for better financial and clinical outcomes.

Watch the Full Webinar

Missed the session? Watch the full webinar here for expert insights into F2F compliance, PDGM optimization, and OASIS scoring accuracy.

Special Offer: Get a PDGM Utilization Analysis

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More on PDGM

Optimize PDGM Performance with SimiTree | Maximize Revenue Opportunities » SimiTree

PDGM Case-Mix Weight Optimization: Strategies for Maximum Reimbursement » SimiTree

PDGM Quality Measures: The Key to Revenue Growth in Home Health » SimiTree

Optimize Resource Utilization Under PDGM: Strategies for Home Health Success » SimiTree

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