Methodology
How Upheld calculates scores and dollars
Transparent formulas for agency QA and revenue leaders. All dollar figures are advisory — our PDGM HIPPS grouper is not certified CMS Home Health Grouper Software or a remittance engine. Full technical detail also lives in the repo at docs/calculations.md.
1 · What each number means
- Submission readiness (0–100) — how clean the packet looks for submission (integrity, not payment).
- Expected period total — advisory full 30-day PDGM period pay for this chart (national base × case-mix weight × wage index).
- Capture — upside if documentation/coding is fixed.
- Protect — exposure if submitted as-is.
- Path to 80+ — ordered open findings that drag readiness under the gate.
2 · CMS rate anchors (CY 2026)
30-day national base
$2,038
SN per-visit
$177
Illustrative LUPA gap
$1,153
A certification period is often 60 days and may include two 30-day payments. Upheld models one PDGM payment period at a time.
3 · Expected period payment
Expected $ = National base × HIPPS case-mix weight × Wage index
National base = $2,038 (CMS CY 2026).
PDGM HIPPS grouper maps OASIS / episode signals into the five-character HIPPS code (admission×timing, clinical group A–L, functional A–C, comorbidity 1–3, placeholder 1). Case-mix weight is the product of mid-band component factors for that HIPPS. A valid chart-stated HIPPS is preferred for the weight; mismatches are flagged.
Wage index defaults to 1.0 (national). Agencies can set a local wage index in Settings.
| Pos 2 | PDGM clinical group |
|---|---|
| A | MMTA – Other |
| B | Neuro / Stroke Rehabilitation |
| C | Wounds |
| D | Complex Nursing Interventions |
| E | Musculoskeletal Rehabilitation |
| F | Behavioral Health |
| G | MMTA – Surgical Aftercare |
| H | MMTA – Cardiac / Circulatory |
| I | MMTA – Endocrine |
| J | MMTA – GI / GU |
| K | MMTA – Infectious / Neoplasms / Blood |
| L | MMTA – Respiratory |
Weight is clamped (~0.55–2.8). Full CMS case-mix weight files can replace mid-band factors when loaded.
4 · Capture and protect
Each finding has an advisory $ (from CMS-scaled rules) and type RECOVERY (capture) or EXPOSURE (protect).
Finding $ is scaled to the chart’s expected period: nationalFinding$ × (E / $2,038.22), then capped at E.
Protect: denial-class findings (F2F, homebound, cert, orders) take the maximum once; other exposure is summed; result ≤ E.
Capture: recovery findings are summed and capped at E. Capture and protect are separate paths — do not add them as a new claim total.
5 · Submission readiness
Severity penalties: Critical 22 · High 12 · Medium 6 · Low 2. Each module score = 100 − sum(penalties), or 92 if no findings.
Readiness = 0.35×Clinical + 0.40×Compliance + 0.25×Revenue
Gate for the fix path: 80. Live readiness uses OPEN findings only (resolved/dismissed no longer penalize).
6 · What this is not
- Advisory PDGM HIPPS grouper — not certified CMS HH Grouper Software
- Not a remittance or payment guarantee
- Mid-band component weights today (full CMS weight files can replace them)
- Not a substitute for human clinical/compliance judgment