Recovering Case-Mix Revenue by Capturing PDGM Comorbidity Adjustments
Home health agency (~850 active patients) · Mid-Atlantic U.S.
+11%
Avg Case-Mix Weight
3.1x
Comorbidity Adjustments Captured
$610K
Annual Revenue Recovered
0
New Denials Introduced
How a certified secondary-diagnosis review recovered PDGM comorbidity adjustments an agency was leaving uncoded — lifting average case-mix weight and revenue per 30-day period without a single new patient.
The Challenge
An established home health agency serving roughly 850 active patients suspected it was under-earning on its Medicare periods but could not pinpoint why. Its clean-claim rate was healthy and denials were low — the money was not being lost to rejections. It was never being earned in the first place. When we audited a representative sample of 30-day periods, the pattern was consistent: coders were capturing the primary diagnosis accurately, but secondary diagnoses were being under-documented and under-coded. Under the Patient-Driven Groupings Model, qualifying secondary conditions drive a comorbidity adjustment — none, low, or high — that changes the case-mix weight and therefore the payment. The agency was landing the vast majority of its periods in the "no comorbidity adjustment" tier, even when the clinical record clearly described conditions that would have qualified for a low or high adjustment. Coding to the primary diagnosis and stopping there was quietly costing the agency on nearly every episode.
Our Solution
We put every period through an AAPC-certified secondary-diagnosis review layered on top of the agency's existing workflow. Certified coders read the full clinical picture — referral, H&P, medication list, and OASIS assessment — and coded each documented, active secondary condition to the correct ICD-10-CM specificity, capturing the comorbidities that qualify for PDGM's low and high comorbidity adjustments. Where the documentation implied a qualifying condition but did not clearly support it, we ran a physician-query process rather than coding on assumption — protecting the agency from the over-capture that invites audit exposure. We also fed the recurring gaps back into the OASIS and intake process, so the conditions were documented completely at the source going forward instead of being reconstructed at coding. The result was not aggressive coding; it was complete coding — capturing the acuity the patients actually had and the record already supported.