CMS uses 432 PDGM payment groups to determine Medicare home health reimbursement. Most agencies accept the first grouping their EMR assigns and leave money on the table every episode. ClientCare analyzes diagnosis sequencing across every payment group and shows you exactly where reimbursement is being missed — with an average opportunity of $320 per patient.
Questions? Call Riley at +1 (943) 202-1897
432
PDGM payment groups in CMS model
$320
Avg. per-patient optimization opportunity
12
Clinical categories analyzed per patient
Most agencies accept the first diagnosis grouping their EMR assigns without question. CMS has 432 PDGM payment groups, and the difference between adjacent groups can be hundreds of dollars per 30-day episode. Under-coding is invisible until you analyze what you could have billed.
The primary diagnosis drives the clinical category in PDGM. Reordering secondary diagnoses to a primary position — when clinically supported — can shift a patient into a higher-paying group. Doing this manually across hundreds of patients is impractical.
Reviewing diagnosis codes, functional levels, and comorbidity adjustments for every patient in every episode takes hours. Most agencies skip it entirely or only audit when revenue dips — by which point months of reimbursement have already been left on the table.
Export your patient list with ICD-10 diagnosis codes from any EMR. Upload the CSV to ClientCare. The system maps columns automatically and validates diagnosis codes against the current CMS code set.
For each patient, ClientCare evaluates the primary diagnosis against all 432 PDGM payment groups. It checks clinical categories, functional levels, comorbidity adjustments, and episode timing to identify the optimal grouping.
You receive a ranked list of patients with specific recommendations: which diagnosis to move to primary position, the target payment group, and the dollar impact. Largest opportunities surface first so your coding team focuses where it matters.
Automated analysis across every dimension of the PDGM model — diagnosis sequencing, clinical categories, comorbidities, and episode timing.
ClientCare evaluates every patient's diagnosis list against all applicable PDGM payment groups. When resequencing the primary diagnosis would place the patient in a higher-reimbursement group, you get a specific recommendation with the dollar impact.
The PDGM engine maps each patient to one of 12 clinical categories and cross-references functional levels and comorbidity adjustments. You see exactly which category your patient falls into and whether a higher category is clinically supported.
PDGM payments vary by admission source and episode timing (early vs. late). ClientCare flags episodes where timing classification may be suboptimal and shows the revenue difference between early and late episode rates.
Upload your entire patient roster with diagnosis codes. The PDGM engine processes every patient in a single batch and returns prioritized recommendations sorted by dollar impact — largest opportunities first.
Any agency billing Medicare home health episodes under PDGM. The more patients, the larger the cumulative opportunity.
PDGM is the payment model for every Medicare home health episode. Optimization directly increases per-episode revenue.
Agencies with both HHA and hospice lines benefit from unified diagnosis management across service lines.
SNFs referring patients to home health can ensure episodes are coded optimally before discharge.
Behavioral diagnoses often serve as comorbidity adjustors in PDGM. Proper sequencing matters.
Staffing firms partnering with HHAs can add PDGM optimization as a value-added service.
Residents transitioning to home health episodes benefit from pre-optimized diagnosis coding.
Explore more ClientCare features: