An accurate billing process always starts its journey with the proper documentation process, and your home health billing process is not an exception to it. One of the vital documents that makes the home health billing process a little unique from others is the OASIS-E assessment. This particular documentation process requires your in-house administrative team or third-party home health billing company to gather comprehensive patient information at the start of care. It shows the patient's condition, needs, and care plan. But this data does more than tell a story — it affects how much your agency gets paid. The details you collect help generate an HHRG (Home Health Resource Group) code, which decides your payment under the PDGM model. That's why it's so important to translate OASIS-E data correctly. Always remember that you will always face claim denials and lower payments when you use the wrong HHRG code.
To convert your OASIS-E assessment into an accurate HHRG code, it is crucial to understand the basics of HHRG so that you will always be able to ensure accurate documentation:
Understanding the Basics — What is HHRG?
The Home Health Resource Group (HHRG) code is a key part of PDGM. Medicare uses it to decide how much to pay home health agencies for every 30 days. This code is created from your OASIS-E data and has three characters. Each character shows something different about the patient — like their clinical group based on the diagnosis, how much help they need with daily tasks and any other health issues they may have. These factors are combined to calculate the payment amount.
Here is an example of the HHRG code for you viz. 3CG, where 3 defines that wound care is the primary reason for home healthcare. C represents the high functional impairment, as your patient requires serious help with daily activities, and G shows that your patient has a serious additional health condition.
Since the HHRG code depends entirely on the OASIS-E data, accurate entry is the first and most important step in billing.
Now, you should learn about the step-by-step procedures for converting your OASIS-E data into the right HHRG code and how a home health billing company makes thing convenient for you.
Turning OASIS-E Assessment into HHRG Codes: how a home health billing company helps:
1. Begin with Accurate OASIS-E Data Entry:
Before you start billing, make sure the OASIS-E is filled out correctly. Every answer affects how much you get paid. It includes questions about primary diagnosis, daily living activities, cognitive status, and other health conditions. These answers help place the patient into one of the 12 PDGM clinical groups (particularly diagnosis and care needs) and decide their functional and co-morbidity levels.
2. Understand the PDGM Clinical Groupings:
The next step after completing the OASIS-E is placing your patient into one of the PDGM groups. These PDGM groups are wound care, musculoskeletal rehab, neuro rehab, and complex nursing interventions. You should always select a diagnosis that truly demonstrates the reason why your patient needs home care. The diagnosis must also be on CMS's list of accepted PDGM codes. If it's not, your claim could be denied. For example, if a patient is receiving care for a non-healing surgical wound, using a vague or unrelated diagnosis might put them in the wrong group or make the claim invalid. But if you list a clear, accepted code like "non-pressure chronic ulcer," the patient will be correctly grouped under wound care. That's why many agencies rely on home health billing companies. Their experts stay current on CMS rules and help your team choose the right codes to avoid costly mistakes.
3. Determine the Functional Impairment Level:
Your OASIS-E answers show how well the patient can do daily tasks like bathing, dressing, moving, and using the toilet. Each answer gets a score, and based on the overall score, a patient falls under the category of low, medium, and high functional level of impairment. This affects the second part of the HHRG code and how much your agency is paid. If you say the patient has fewer problems than they really do, you might get paid less. However, if you say the patient has more problems than they have, it could lead to audits or having to pay money back, thus requiring a home healthcare company to report the information very carefully.
4. Calculate the Adjustment of Co-morbidity:
The third character of the HHRG code shows if the patient has other health problems called co-morbid conditions grouped as none, low, or high. OASIS-E lists a patient's secondary diagnoses and compares them to CMS's approved co-morbidity list. If the patient has one or more of these conditions, you can get a higher payment. However, your notes must clearly explain the diagnosis and how it affects care. Just writing "diabetes" is not enough. For example, if a patient with diabetes has a slow-healing foot ulcer, your notes should say how diabetes is causing the problem and how you are treating it. Without this detail, a higher payment might be denied. That's why clear and complete documentation is very important.
5. Ensure the Proper Application of Source and Time of Admission:
PDGM also considers when the patient started care and where they came from. Timing refers to whether it's an early or late 30-day payment period.
The source of admission says if your patient came from a community or hospital. This information doesn't show up in the HHRG code itself but affects the case-mix weight, which helps determine how much your agency gets paid. Early episodes and hospital admissions usually lead to higher reimbursements. OASIS-E collects this data automatically, but it must be verified and matched with the claim. Many home health agencies face payment delays or denials when hospital records or discharge papers are missing.
6. Use Grouper Software to Generate HHRG Code:
After you enter all the patient data, a CMS-approved tool like the Home Health PPS Grouper takes that information and creates the final HHRG code. It uses your OASIS-E answers, diagnosis codes, admission timing, and admission source to calculate the HHRG code, case-mix weight, and payment amount. This tool only works well if the data is correct. Mistakes in OASIS-E or coding can lead to wrong codes, which may cause claim denials or wrong payments. That's why many home health agencies work with home health billing companies. These experts use advanced tools to double-check every detail before submitting claims to CMS, helping avoid payment delays and rejections.
7. Submit the Claim and Monitor Payment:
After the HHRG code is ready, your billing team sends the Request for Anticipated Payment (RAP) and later the final claim. Both must match the OASIS-E and include the right codes. Even a small error, like a wrong date or mismatched diagnosis, can cause the claim to be denied. For example, if your OASIS-E says the patient was admitted on June 1, but your claim says June 2, Medicare may reject it. That's why real-time monitoring and double-checking every detail is so important.
Medicare audits are on the rise. CMS is closely checking if your OASIS-E data matches what you bill for. Mistakes can lead to lower payments, recoupment, or even legal issues. PDGM rules are complex, and small home health agencies often struggle to manage them all. That's why many turn to professional RCM company. These experts do more than submit claims — they make sure your OASIS-E, HHRG code, and final claim match.
Finally, Hire the Perfect Home Health Billing Company:
The road from OASIS-E to HHRG is long, but each step plays a key role in how your agency is paid. From accurate assessments to proper coding, everything must be aligned. Mistakes can cost you — not just in revenue, but in compliance risk.
Investing in the right billing partner helps you avoid those costly mistakes. A professional billing company can offer the accuracy, oversight, and speed you need to navigate PDGM with confidence. So, don't let yourself and your clinical staff get diverted from patient care. Ensure this by outsourcing your end-to-end billing to a professional home health billing company.
Website of Source: https://sunknowledge.com/
Source: Story.KISSPR.com
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