A Web-based Solution for PDGM Home Care Coding: Home Case Mixer
We have developed a web-based tool for Patient-Driven Groupings Model (PDGM) clinical coding & analytics called Home Case Mixer. It is a web-based application that provides an exhaustive case-mix analysis accessible from a browser on any device. It can be used with an existing EHR, referral documentation, or a document that conforms to the Outcome Assessment Information Set (OASIS) Data Submission Specification.
Amara Home Care, where I work as Deputy Administrator and Chief Medical Informatics Officer, has been in business as a Home Healthcare agency (HHA) for 21 years. It has experienced and survived many disruptive changes: the introduction of MyCare Ohio in 2014, the adoption by the Centers for Medicare & Medicaid Services (CMS) of a new payment system for home care providers based on diagnosis-related groups (DRGs) called Patient-Driven Groupings Model (PDGM), right before the onset of the COVID-19 pandemic, and the pandemic itself, just to name a few. However, the biggest challenge throughout its operations was the financial burden due to the minimal profit margins, an almost universal challenge in the industry. As a result, reimbursement and revenue cycle management are of critical importance.
Home Case Mixer began as an internal project within Amara Home Care to consolidate and automate our clinical coding and Quality Assurance by developing an independent software implementation of the Centers for Medicare & Medicaid Services (CMS) Home Health Grouper Software (HHGS). Building on my experience developing large, custom patient registries, using modern dynamic web frameworks for enterprise applications, and developing web standards, this project evolved from an internal tool into an independent application.
Home healthcare agencies’ use of Electronic Health Record (EHR) systems is a critical component of their operations which comes with many recognized benefits: the ability to communicate with other clinicians, highlight essential information, and the availability of all the information for providing care for the patient [1].
Despite this, many studies have demonstrated low satisfaction with these systems in home care. One of the most prevailing themes in the discussions around their limitations is poor usability and functionality [1, 2]. When prompted to suggest improvements, most study participants suggest adding functions to these systems [1]. However, many HHA’s are often forced to compromise on a system that implements essential features sufficiently, systems which are effectively jacks of all trades and masters of none.
Clinical coding is the transformation of information about a patient’s episode of care, often from multiple, disparate systems, into structured codes. The codes are from a terminology management system like ICD-10 (International Classification of Diseases, Tenth Revision) [3]. Although many HHA EHRs include clinical coding functionality, agencies often need to outsource their clinical coding needs to third-party solutions or staff. The process is often time-consuming and requires expertise or familiarity with ICD-10. The codes produced by clinical coding often represent DRGs.
DRGs are a patient classification scheme which provides a means of relating the type of patients a hospital treats (i.e., its case mix) to the costs incurred by the [provider] [4]
In home care, the patient problem list is an important
component of admission, care planning processes, and concise communication of a patient’s clinical status [2]. Studies of these processes and the clinical documentation from the referring facility did not find initial referral documentation reliable as a single source of the patient problem list, and they are often inaccurate or outdated [2]. The problems are usually included as textual summaries of the underlying ICD-10 diagnoses in the original medical information systems rather than as the ICD-10 codes themselves. So, the challenging task of clinical coding is greatly aided by tools that provide a way to look up ICD-10 diagnoses by text searching among the standardized labels and synonyms within the ICD-10 terminology system and labels from other interoperable medical terminology systems. Tools that allow ICD-10 diagnoses to be searched within these related terminology systems by category are also helpful.
We will be releasing Home Case Mixer as a product this summer. If you are a home care agency interested in a web-based clinical coding solution that provides everything you need to ensure you are capturing your patient’s case-mix and maximizing your PDGM reimbursement, you can contact us to learn more about Home Case Mixer and the opportunity to be an early adopter.
You can check out the demonstration of the software’s core features here.
[1] Hobensack, Mollie, et al. “Home healthcare clinicians’ perspectives on electronic health records: a qualitative study.” (2021).
[2] Sockolow, Paulina S., et al. “Incongruence of patient problem information across three phases of home care admission: There’s a problem with the problem list.” MEDINFO 2019: Health and Wellbeing e-Networks for All. IOS Press, 2019. 803–807.
[3] Dong, Hang, et al. “Automated clinical coding: what, why, and where we are?.” NPJ digital medicine 5.1 (2022): 159.