As home health agencies continue to plan for the implementation of PDGM there are some very important questions that agencies should be asking of the software vendors/electronic medical records (EMR) that will be utilized for clinical documentation and billing of Medicare Home Health claims.



  1. Are the acceptable primary diagnoses built into the EMR so that agencies would be notified immediately if an unacceptable primary is being used?
  2. From what part of the EMR will the diagnosis coding be extracted to report on the claim?
  3. What is the process for updating diagnoses if there is a change in condition in the first 30-day period of a 60-day episode?
  4. Where will the agency update the diagnosis coding in the EMR if the patient has a change in diagnoses codes after the SOC or Recertification is complete?
  5. How will a Resumption of Care or Other Follow-Up OASIS, from a first 30-day payment period, be linked to the second 30-day final claim for purposes of appropriate Functional category scoring?
  6. Will the EMR have any OASIS scrubbing capabilities to support OASIS accuracy, especially in the ADLs?



  1. Will the system automatically give agencies both the HIPPS code and LUPA threshold at each 30-day period?
  2. Will the EMR create estimated revenue for each 30-day payment period as all the pieces for creating a HIPPS code are in place?
  3. Will there be a warning/alert to recommend agencies review the second 30-day payment HIPPS code and LUPA threshold?
  4. Will the EMR be able to create both a PPS HIPPS code and a PDGM HIPPS code well into the year as Medicare Advantage plans will not all be accepting PDGM HIPPS codes?


Admission Source/Timing

  1. Where will the agency report the Admission Source in the EMR to be used on the claim?
  2. Where will agencies note in the EMR that patient has had a hospital admission and discharge in the first 30-day period of a 60-day episode?
  3. Where will the agency enter the discharge date from a qualifying facility discharge to be reported on the claim with Occurrence code 61 or 62?
  4. Will there be any auto eligibility verification of the patient to establish Early vs. Late at a Start of Care or will the agency be fully responsible for verifying this?
  5. If the agency is responsible for verifying Early vs. Late where will this be entered in the EMR?


Review Choice Demonstration (RCD)

  1. Will there be special concessions in the EMR to assist agencies with being able to submit both 30-day payment periods in the same Pre-Claim Review (PCR) submission, assuming they are in the PCR option?


RAPs & Final Claims Processing

  1. Will the EMR have edits properly in place for clearing a RAP to be sent for each 30-day period?
  2. Will the EMR have edits to prohibit a claim from being released until OASIS is transmitted and accepted and signed orders have been signed and returned to agency?
  3. More specifically, will the EMR prohibit the second 30-day claim from being filed if the Plan of Care has not been returned signed and dated? And will the EMR validate the correct OASIS is in the database?
  4. Will the EMR prohibit a 62 Occurrence Code from being used on any claim except a first 30-day claim in a SOC?
  5. Will the EMR have the capability of filing Medicare Secondary Payer claims with PDGM HIPPS codes?
  6. Will agencies have the capability of electronic cashing posting in the EMR?


Quality Reporting/Star Rating/Value Based Purchasing (VBP)

  1. Will there be any reporting in the EMR that will assist the agency in tracking their status in outcomes and star ratings?
  2. If the agency is in a VBP state, will the EMR assist in monitoring their current year status with VBP outcomes?


PDGM Reporting

  1. Will the agency be able to obtain reporting by PDGM HIPPS code? LUPA Threshold? Primary Diagnosis? Functional Status Category?


This list is the top 25 questions that we feel necessary for agencies to ask of their EMR in preparation for PDGM.  This list can assist agencies with their current vendors as well as assist agencies that are looking for a new EMR.

We are less than 3 months from implementation of PDGM and our EMRs must succeed in providing the necessary support for agencies to thrive under PDGM.

Healthcare Provider Solutions understands that thorough preparation is the key to success under PDGM.

We are dedicated to supporting HHAs with a customized PDGM Impact Analysis, outsourced billing solutions, and continued PDGM education. Our team of seasoned industry professionals is currently guiding agencies nationwide to a smooth PDGM transition.

Prepare for PDGM Success