Live checks, plus what's in development
Risk adjustment that protects payment and quality scores.
A functional or clinical grouping score that's off by one level can shift PDGM payment by $600 or more per episode — across a 100-patient census, that's a five- or six-figure swing in a year. And OASIS/PDGM mismatches are named among the top recurring causes of home health claim denials industry-wide, alongside comorbidity capture gaps. Under-coded complexity doesn't just cost reimbursement today — it sets an artificially low bar CMS then measures your outcomes against tomorrow. MsJaneHH checks both sides of that gap, with the same deterministic, cited approach as every other rule.
Live today
Three checks protect case-mix accuracy on every episode, tested and running now.
NOA timing live
Flags admissions approaching the 5-day Notice of Admission filing deadline while there's still time to file.
LUPA risk live
Flags episodes on pace to fall under the visit-count threshold for their HHRG, before the period closes.
Classification accuracy live
Recalculates admission source and episode timing from claims history and flags any mismatch against what was submitted.
In development
The next layer goes deeper into what actually sets the case-mix weight and the quality-measure baseline: the patient's coded complexity itself.
Comorbidity adjustment
Maps secondary diagnoses to CMS's published comorbidity subgroups and calculates the Low/High adjustment tier — the same lookup CMS's own grouper uses, run against your data before submission instead of after.
Clinical grouping validator
Recalculates the clinical group from the principal diagnosis and flags any mismatch against what was submitted — the first and largest lever in PDGM case-mix weight.
Diagnosis specificity check
Flags cases where the documentation supports a more specific ICD-10 code than what was coded — the kind of gap that quietly costs both reimbursement and quality-measure accuracy.
HIPPS cross-validation
Recalculates the HIPPS code from clinical grouping, functional level, comorbidity tier, admission source, and timing — then compares it to what was actually submitted on the claim.
Functional impairment level check
Cross-checks Section GG functional scoring for internal consistency — the same scores that set the functional-level dimension of case-mix weight.
HHVBP tracking
Estimates your Total Performance Score from the same OASIS-derived quality measures CMS uses, so payment-year impact is visible well before CMS's own feedback report arrives.
Why this protects more than payment
Home health quality measures — the ones behind your public Star Rating — are risk-adjusted using a model built largely on the same OASIS data that drives PDGM case mix. If a patient's real complexity isn't fully captured, CMS's expected-outcome baseline for that patient gets set too low. Your agency's actual outcomes then get compared against a bar that doesn't reflect who you're actually caring for — making solid care look worse than it is. Complete, accurate documentation isn't just a reimbursement question. It's a reputation one too.
Status, stated honestly: the three checks above are live and tested. The comorbidity, clinical grouping, diagnosis specificity, HIPPS, functional level, and HHVBP work is in active development — none of it is shipped yet, and this page will update as each piece goes live in pilot, the same way the rev cycle page does.