OASIS and the PDGM: How OASIS Plays a Role in the New Payment Model

The landscape of healthcare reimbursement has undergone significant shifts in recent years. One of the most notable changes is the introduction of the Patient-Driven Groupings Model (PDGM), a new payment system implemented by the Centers for Medicare & Medicaid Services (CMS) for home health agencies. This model is designed to replace the old Home Health Prospective Payment System (HH PPS), which previously based reimbursements largely on the volume of visits. PDGM is aimed at more accurately reflecting patient needs and care intensity.

One critical element in PDGM’s implementation is the OASIS (Outcome and Assessment Information Set) assessment. OASIS has long been a cornerstone in home healthcare, providing essential data for clinicians, administrators, and payers. But under PDGM, OASIS takes on an even more vital role in determining the reimbursement rates, care planning, and the overall success of the patient care process. In this blog, we will explore the Patient-Driven Groupings Model, explain how OASIS assessments fit into it, and break down how OASIS impacts coding, reimbursement, and care planning.

Overview of the Patient-Driven Groupings Model (PDGM)

Before diving into OASIS’s role in PDGM, it’s essential to first understand what PDGM is and why it was implemented. PDGM, which came into effect in 2020, aims to shift the focus of home health reimbursement from the volume of services provided to the value and intensity of the care patients need.

Key Components of PDGM

1. Clinical Grouping: PDGM uses the patient’s primary diagnosis to classify them into one of 12 clinical groups, such as musculoskeletal, neurological, or cardiovascular issues. This classification is designed to capture the patient’s primary medical condition, ensuring that those who require more intensive care receive higher reimbursement.

2. Functional Impairment Level (FIM): This aspect evaluates the severity of a patient’s functional impairments, including their ability to perform activities of daily living (ADLs). Higher levels of impairment typically result in higher reimbursement due to the increased care requirements.

3. Comorbidity Adjustment: This component accounts for any secondary conditions that a patient may have, adjusting the payment based on the presence of additional diagnoses. More comorbidities often indicate a need for more complex care and therefore higher reimbursement.

4. Admission Source and Timing: PDGM differentiates between patients who are admitted to home health services after a hospital stay versus those who are not, as well as the timing of the admission (early versus late in the 30-day episode). This timing is important because patients who are admitted earlier in the 30-day episode tend to have higher costs, thus influencing payment rates.

By focusing on these elements, PDGM ensures that reimbursements are more closely tied to the care needs of the patient rather than the number of visits they receive. OASIS is key to providing the data that helps define these elements.

The Role of OASIS in PDGM

What is OASIS?

The OASIS (Outcome and Assessment Information Set) is a comprehensive set of standardized assessment tools used by home health agencies to collect patient information. It is a key part of ensuring that home health agencies maintain high-quality care while also complying with regulatory and reimbursement standards. The information gathered through OASIS is used to assess patients’ health status and outcomes, ultimately influencing care planning and reimbursement rates.

OASIS collects data across multiple domains, including:

• Demographic information (e.g., age, sex, race)
• Health conditions and diagnoses
• Functional status (e.g., ability to perform activities of daily living)
• Clinical outcomes (e.g., pain, medication management)
• Risk for adverse events (e.g., falls, hospitalization)
• Care needs and interventions

Each of these elements feeds into the broader understanding of the patient’s condition and needs, and under PDGM, the data collected through OASIS directly impacts the reimbursement process and care delivery.

How OASIS is Integrated into PDGM

PDGM relies heavily on OASIS data to determine the appropriate clinical groupings and severity levels for each patient. The information collected in OASIS assessments is used to assign patients to specific clinical groupings and to assess their functional impairment, both of which influence reimbursement.

1. Clinical Groupings: The patient’s primary diagnosis, collected via OASIS, is used to assign them to one of the 12 clinical groupings in PDGM. For example, a patient with chronic obstructive pulmonary disease (COPD) would fall under the respiratory clinical group, while a patient with a hip replacement would be classified under musculoskeletal disorders. These clinical groups are critical in determining the base payment rate for the patient.

2. Functional Impairment Level: The functional status of the patient is another key component captured by OASIS. The assessment includes questions regarding the patient’s ability to perform basic activities of daily living, such as bathing, dressing, and eating. PDGM utilizes this data to determine the level of care the patient needs, which influences the reimbursement rate.

3. Comorbidities: The presence of comorbid conditions can significantly impact the care required by a patient. OASIS captures information about the patient’s additional diagnoses, and this data is used to adjust the PDGM payment to reflect the complexity of the patient’s condition.

4. Admission Timing and Source: OASIS also helps to determine the patient’s admission source and timing, both of which are important factors in PDGM. For example, if a patient is admitted from a hospital stay (rather than a physician’s referral or directly from home), this would be reflected in the OASIS data. PDGM assigns higher payment rates for patients who are admitted after a recent hospitalization, recognizing that they may require more intensive home health services.

How OASIS Impacts Coding, Reimbursement, and Care Planning under PDGM

1. OASIS and Coding

In PDGM, accurate coding is essential to ensure that patients are classified into the correct clinical grouping and functional impairment levels. OASIS assessments directly contribute to the coding process by providing detailed information about a patient’s medical condition, functional abilities, and comorbidities.

• Accurate Diagnosis Coding: The primary diagnosis captured in the OASIS assessment plays a critical role in the coding process. Accurate coding of the diagnosis ensures that the patient is assigned to the correct clinical group, which ultimately affects reimbursement.

• Functional and Comorbidity Coding: The functional status and comorbidity information collected through OASIS also inform coding decisions. If the patient has significant comorbidities, the severity and complexity of care can be adjusted accordingly in the payment model, increasing the reimbursement rate.

Coding mistakes or inaccuracies can lead to improper payment rates or the wrong clinical grouping, which could negatively impact both reimbursement and patient care.

2. OASIS and Reimbursement

Reimbursement is directly tied to the data collected through OASIS assessments under PDGM. As mentioned, PDGM relies on several key factors to calculate the reimbursement rate, including clinical grouping, functional impairment, comorbidities, and admission timing.

• Higher Reimbursement for More Complex Cases: PDGM ensures that patients with higher levels of complexity or care requirements are reimbursed at a higher rate. For instance, a patient with multiple comorbidities or significant functional impairments would fall into a higher reimbursement category. Accurate OASIS data helps ensure that home health agencies are reimbursed appropriately for the level of care they provide.

• Impact of Functional Impairment: A patient who requires assistance with daily living activities, as reflected in their OASIS assessment, may receive a higher payment to account for the additional care they need. This aligns the reimbursement system with the intensity of services provided rather than the number of visits.

• Impact of Admission Source and Timing: OASIS data related to a patient’s admission source (hospital versus non-hospital) and the timing of admission (early versus late in the 30-day episode) affects reimbursement rates. For example, patients admitted from the hospital may be assigned to a higher payment category due to their increased care needs.

3. OASIS and Care Planning

One of the core goals of PDGM is to provide high-quality care that is personalized to each patient’s unique needs. OASIS assessments are essential in developing accurate and effective care plans, as they provide a detailed picture of the patient’s health status, needs, and goals.

• Identifying Patient Needs: The OASIS assessment captures crucial information regarding the patient’s functional status, risk factors, and clinical needs, allowing home health agencies to create individualized care plans. For instance, if a patient’s OASIS assessment indicates a high level of functional impairment, the care plan may include more frequent visits, additional therapeutic interventions, or a focus on specific ADLs.

• Tracking Outcomes: OASIS data is also used to track patient outcomes over time. Home health agencies can monitor changes in a patient’s condition, such as improvements in mobility or a reduction in pain, and adjust care plans accordingly. This process of continual assessment and adjustment ensures that patients are receiving the most appropriate care based on their evolving needs.

• Ensuring Compliance with Regulatory Requirements: OASIS also plays a role in ensuring that home health agencies are complying with CMS regulations and quality measures. Accurate completion of OASIS assessments is crucial for demonstrating that the patient is receiving the right care and for maintaining the agency’s standing in the Medicare program.

Conclusion

The integration of OASIS into the Patient-Driven Groupings Model (PDGM) represents a major shift in how home health services are reimbursed and delivered. Under PDGM, OASIS assessments play a central role in determining clinical groupings, functional impairment levels, comorbidity adjustments, and the timing of admissions. This data is used to ensure that home health agencies are appropriately reimbursed for the care they provide and that patients receive the care they need.

By influencing coding, reimbursement, and care planning, OASIS is a crucial tool for navigating the complexities of PDGM. Its ability to provide detailed patient data ensures that home health agencies can make informed decisions that benefit both their bottom line and their patients’ health outcomes. As the healthcare landscape continues to evolve, the role of OASIS in PDGM will undoubtedly remain a cornerstone of effective home healthcare delivery.