There exists much confusion regarding routine medical supplies in the HHA industry. The PPS rule states that the cost of routine medical supplies is bundled into the HHA’s PPS reimbursement. As such, HHA’s may not bill separately for routine supplies. Routine supplies are “supplies that are customarily used in small quantities during the course of most home care visits. Routine supplies would not include supplies specifically ordered by the physician or are essential to HHA personnel in order to effectuate the plan of care.”
Examples of supplies which are usually considered routine medical, but are not limited to:
A) Dressings and Skin Care
B) Infection Control Protection
C) Blood Drawing Supplies
D) Incontinence Supplies
If the above items are required in quantity, for a recurring need, these supplies may be considered non-routine and this may be a billable supply. This should be confirmed with your local Intermediary prior to billing.
Monday, December 28, 2009
Monday, December 14, 2009
NEW CHANGE OF OWNERSHIP/TRANSFER OF STOCK PROHIBITIONS
Effective, January 1st, 2010 all HHA transfers of stock and those that are defined as a Change of Ownership (CHOW), which occur prior to the expiration of 36 months from the receipt of the HHA’s Medicare certification, will require that the acquiring party or entity enroll as a new provider via a CMS 855A and undergo a state survey or accreditation. This will cause a gap in billing from the time CMS-RO pends all claims of the deactivated HHA until the new provider agreement is activated.
Friday, December 11, 2009
MANAGEMENT AND EVALUATION
The 2010 PPS Rule clarifies the rule that in the house health setting, management and evaluation of a patient care plan is considered a reasonable and necessary skilled service only when underlying conditions or complications are such that a registered nurse can ensure that essential non-skilled care is achieving its purpose. (42 C.F.R. 409.42(c)(1)(i))
Patient Education Services
The 2010 PPS Rule clarifies when patient education services constituted skilled services would be deemed to no longer be needed when it became apparent, after a reasonable period of time, that the patient, family, or caregiver would not be trained. Further teaching and training would cease to be reasonable and necessary in this case and would cease to be considered a skilled service. The services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching on training was unsuccessful.
Patient Education Services
The 2010 PPS Rule clarifies when patient education services constituted skilled services would be deemed to no longer be needed when it became apparent, after a reasonable period of time, that the patient, family, or caregiver would not be trained. Further teaching and training would cease to be reasonable and necessary in this case and would cease to be considered a skilled service. The services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching on training was unsuccessful.
Monday, December 7, 2009
2010 HHA PPS OUTLIER CAP AND NEW HHA CONGRESSIONAL CUTS
Beginning calendar year 2010, CMS will cap home health outlier payments at 10% per HHA and target total aggregate outlier payments at 2.5% of all HH PPS payments. This is an agency level cap such that in any given calendar year, an individual HHA would receive no more than 10% of its total HH PPS payments in outlier payments.
In a 12/05/09 New York Times article, the impact of this legislation has been a topic of interest during the first week of Senate debate. Under Congress’s new legislation to insure more than 30 million Americans, home care would be hit disproportionately hard. Home care currently accounts for 3.7% of the Medicare budget but would take a 10.2% hit by the House bill and 9.4% hit by the Senate bill. This translates into a $55 billion reduction over 10 years in Medicare spending on home health services under the House bill and a $43 billion reduction under the Senate bill.
In a 12/05/09 New York Times article, the impact of this legislation has been a topic of interest during the first week of Senate debate. Under Congress’s new legislation to insure more than 30 million Americans, home care would be hit disproportionately hard. Home care currently accounts for 3.7% of the Medicare budget but would take a 10.2% hit by the House bill and 9.4% hit by the Senate bill. This translates into a $55 billion reduction over 10 years in Medicare spending on home health services under the House bill and a $43 billion reduction under the Senate bill.
Wednesday, November 18, 2009
HHA PLAN OF CARE FALSE CLAIMS ACT SETTLEMENT
HHA Agrees to Pay $2 Million to Resolve Claims of Failure to Collect Doctor Approvals
An Indiana home health care agency (HHA) and its parent company agreed to pay almost $2 million to resolve allegations it violated the False Claims Act by failing to obtain certain required physician approvals before submitting bills to Medicare, the Department of Justice announced Oct. 20.
The statement said that certain required physician signatures were not timely collected before final claims were submitted to Medicare, the DOJ release said.
In addition, certain documentation supporting the Outcome & Assessment Information set data for the claims did not exist, according to the settlement agreement.
An Indiana home health care agency (HHA) and its parent company agreed to pay almost $2 million to resolve allegations it violated the False Claims Act by failing to obtain certain required physician approvals before submitting bills to Medicare, the Department of Justice announced Oct. 20.
The statement said that certain required physician signatures were not timely collected before final claims were submitted to Medicare, the DOJ release said.
In addition, certain documentation supporting the Outcome & Assessment Information set data for the claims did not exist, according to the settlement agreement.
Saturday, October 24, 2009
Home Health Coalition Questions and Answers
At a July 13th, 2009 PGBA meeting, the following information was provided by the Intermediary regarding an inpatient admission issue:
“A beneficiary does not have to be discharged from home care because of an inpatient admission.” An agency did not discharge at the beginning of the recertification period because they did not believe there was a need to based on the above quoted statement. The scenario is the recertification was completed as required but the patient was transferred to inpatient hospital before the beginning of the recertification period. When the patient was discharged from the hospital, which was the first visit after the beginning of the recertification period, a resumption of care was completed. Their claim is being denied due to overlapping services. What needs to be added to the claim so the agency is appropriately reimbursed?
The following reference was provided for that question in the July 13th, 2009 answer. Reference: The Centers for Medicare and Medicaid Services (CMS) Internet Only Manual (IOM) Pub. 100-04, Medicare Claims Processing Manual Chapter 10, Section 10.1.14 Home Health Agency Billing. Within this Section of the manual it states:
“Note that beneficiaries do not have to be discharged within the episode period because of admissions to other types of health care providers (i.e., hospitals, skilled nursing facilities), but HHAs may choose to discharge in such cases. When discharging, full episode payment would still be made unless the beneficiary received more home care later in the same 60-day period. Discharge should be made at the end of the 60-day episode period in all cases if the beneficiary has not returned to the HHA, and is not expected to return for treatment under any existing plan of care”.
Therefore, it is the provider’s choice whether or not to officially discharge the patient and submit a final claim. Additionally, this section of the manual reminds providers that without an early discharge date, 60-day episodes stand alone. If the 60-day episode ends while the patient is still hospitalized, recertification and a new plan of care will need to be done.
If the provider decides to leave the patient open to the current episode, there will not be an overlap of services if the patient returns to the agency within the 60 days because the HHA will not have line item dates of service on the same dates as the inpatient facility billing days.
The provider might also decide to discharge a patient immediately at the time of admission to a skilled facility. That is a decision that is made by the agency. However, in this scenario, should the patient return to the agency before the episode is over, a new SOC would be established and the first part of the episode would be PEP’d.
If the patient is “left open” to the home health episode, and the episode ends, the HHA should submit a final claim once the 60 day episode is finished. After that, should the patient be discharged from the facility back to a home health agency, a new episode and SOC would be done.
“A beneficiary does not have to be discharged from home care because of an inpatient admission.” An agency did not discharge at the beginning of the recertification period because they did not believe there was a need to based on the above quoted statement. The scenario is the recertification was completed as required but the patient was transferred to inpatient hospital before the beginning of the recertification period. When the patient was discharged from the hospital, which was the first visit after the beginning of the recertification period, a resumption of care was completed. Their claim is being denied due to overlapping services. What needs to be added to the claim so the agency is appropriately reimbursed?
The following reference was provided for that question in the July 13th, 2009 answer. Reference: The Centers for Medicare and Medicaid Services (CMS) Internet Only Manual (IOM) Pub. 100-04, Medicare Claims Processing Manual Chapter 10, Section 10.1.14 Home Health Agency Billing. Within this Section of the manual it states:
“Note that beneficiaries do not have to be discharged within the episode period because of admissions to other types of health care providers (i.e., hospitals, skilled nursing facilities), but HHAs may choose to discharge in such cases. When discharging, full episode payment would still be made unless the beneficiary received more home care later in the same 60-day period. Discharge should be made at the end of the 60-day episode period in all cases if the beneficiary has not returned to the HHA, and is not expected to return for treatment under any existing plan of care”.
Therefore, it is the provider’s choice whether or not to officially discharge the patient and submit a final claim. Additionally, this section of the manual reminds providers that without an early discharge date, 60-day episodes stand alone. If the 60-day episode ends while the patient is still hospitalized, recertification and a new plan of care will need to be done.
If the provider decides to leave the patient open to the current episode, there will not be an overlap of services if the patient returns to the agency within the 60 days because the HHA will not have line item dates of service on the same dates as the inpatient facility billing days.
The provider might also decide to discharge a patient immediately at the time of admission to a skilled facility. That is a decision that is made by the agency. However, in this scenario, should the patient return to the agency before the episode is over, a new SOC would be established and the first part of the episode would be PEP’d.
If the patient is “left open” to the home health episode, and the episode ends, the HHA should submit a final claim once the 60 day episode is finished. After that, should the patient be discharged from the facility back to a home health agency, a new episode and SOC would be done.
What’s New About the OASIS-C Numbering System.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
What’s New About the OASIS-C Numbering System.
The OASIS-C represents the most comprehensive revision to OASIS since its original release in 1999. Please note that, with the exception of the tracking items and M0903/M0906, the OASIS-C items have been renumbered; thus the OASIS-B1 M0 item numbers do not correspond to the new OASIS-C numbering scheme.
Table 1: OASIS-C Numbering System.
Patient Tracking Items M0010 - M0069; M0140 – M0150
Clinical RecordsM0080 – M0110
Patient History Diagnoses -M1000s
Living Arrangements-M1100
Sensory Status-M1200s
Integumentary Status-M1300s
Respiratory Status-M1400s
Cardiac Status-M1500s
Elimination Status-M1600s
Neuro/Emotional Behavioral Status -M1700s
ADLs/IADLs-M1800s + M1900s
Medications-M2000s
Care Management-M2100s
Therapy Need and Plan of Care-M2200s
Emergent Care-M2300s
Date Collected at Transfer/Discharge -M2400s, M0903 + M0906
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Time Points
OASIS-C data are collected at the following time points:
Start of Care
Resumption of Care following inpatient facility stay
Recertification within the last five days of each 60-day recertification period
Other Follow-Up
Transfer to inpatient facility
Discharge from home care
Death at home
All of these assessments, with the exception of transfer to inpatient facility and death at home, must be conducted during a home visit because all require the clinician to have an in-person encounter with the patient. The transfer to an inpatient facility requires collection of limited OASIS data (most of which may be obtained through a telephone call).
At the start of care time point, the comprehensive assessment should be completed within five days of the start of care date. At the resumption of care, the comprehensive assessment must be completed within 48 hours of inpatient facility discharge. For the transfer to inpatient facility, discharge from home care, death at home, and other follow-up, the assessments must be completed within 48 hours of becoming aware of the transfer, discharge, death, or significant change in condition.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Who completes OASIS-C?
As identified in (M0080) Discipline of Person Completing Assessment, the comprehensive assessment and OASIS data collection should be conducted by a registered nurse (RN) or any of the therapies (PT, SLP/ST, OT). An LPN/LVN, PTA, OTA, MSW, or Aide may not complete OASIS assessments.
In cases involving nursing, the RN completes the comprehensive assessment at SOC. Any discipline qualified to perform assessments – RN, PT, SLP, OT – may complete subsequent assessments. For a therapy-only case, the therapist usually conducts the comprehensive assessment. It is acceptable for a PT of SLP to conduct and complete the comprehensive assessment at SOC. An OT may conduct and complete the assessment when the need for occupational therapy establishes program eligibility. Note: Occupational therapy alone does not establish for the Medicare home health benefit at the start of care; however, occupational therapy may establish eligibility under other programs, such as Medicaid. The Medicare home health patient who is receiving services from multiple disciplines (i.e., skilled nursing, physical therapy, and occupational therapy) during the episode of care, can retain eligibility if, over time, occupational therapy is only remaining skilled discipline providing care. At that time, an OT can conduct OASIS assessments.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Section 484.20(a) Standard: Encoding OASIS Data
Once the comprehensive assessment has been completed and OASIS data collected, HHAs enter the OASIS information into the computer system, which we call “encoding.” All the time points of the OASIS assessments have a uniform time frame of thirty days from the date the assessment is completed. (M0090 – Date Assessment Completed) for encoding and submitting data. Once the OASIS data are encoded (in software available from CMS or other software that conforms to the CMS standard electronic record layout, edit specifications, and data dictionary), the agency will review each assessment and edit it for transmission to the State Agency. During this preparation period, the HHA must run software application that subjects each patient data set to the CMS edit specifications and makes it transmission –ready. The agency must correct any information that does not pass the CMS specified edits (e.g., data is missing, incorrect, or inconsistent). Staff entering data may need to contact the qualified clinician who assessed the patient for assistance and clinical notes, which document the assessment, are better at a point in time closer to the assessment activity than if the edits and corrections are delayed.
HHAs have flexibility in the method used to encode their data. Data can be encoded directly by the skilled professional who conducts the assessment into a laptop or hand held computer, by a clerical staff member from a hard copy of the completed assessment, or by a data entry operator or service with whom the HHA may contract to enter the data. Any of these acceptable methods of meeting the regulatory reporting requirements for OASIS. However, the HHA is ultimately responsible for meeting the reporting requirements as well as maintaining patient confidentiality.
Non-clinical staff may not assess patients or complete assessment items; however, clerical staff or data entry operators may enter into the computer the OASIS data collected by the skilled professional. In entering the data, HHAs must comply with all requirements for safeguarding the confidentiality of protected health (patient-identifiable) information.
Once the OASIS data are encoded, HHAs use their software to review and edit the data prior to transmission to the State Agency. When editing the data prior to the transmission, it is important to remember that the edits include an electronic safety net to preclude the transmission of erroneous or inconsistent information and enforce he required formatting for the data set items. When transmitted, the patient assessment data are stabilized at the time point of the assessment, preventing the override of current assessment information with future or past information.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Section 484.20(b) Standard: Accuracy of Encoded OASIS Data
The encoded OASIS data must accurately reflect the patient’s status at the time the information is collected. Before transmission, the HHA must ensure that data items on its own clinical record match the encoded data that are sent to the State. We expect that once the qualified skilled professional completes the assessment, the HHA will develop a means to ensure that the OASIS data input into the computer and transmitted to the State Agency (or CMS contractor) exactly reflect the data collected by the skilled professional. Appendix B contains recommendations for conducting data quality audits on a routine basis and includes information from the original OASIS Implementation Manual (Chapter 12). In addition, the State survey process for HHAs may include review of OASIS data collected versus data encoded and transmitted to the State.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Section 484.20(c) Standard: Transmittal of OASIS Data
The encoded OASIS data must accurately reflect the patient’s status at the time the information is collected. Before transmission, the HHA must ensure that data items on its own clinical record match the encoded data that are sent to the State. We expect that once the qualified skilled professional completes the assessment, the HHA will develop a means to ensure that the OASIS data input into the computer and transmitted to the State Agency (or CMS contractor) exactly reflect the data collected by the skilled professional. Appendix B contains recommendations for conducting data quality audits on a routine basis and includes information from the original OASIS Implementation Manual (Chapter 12). In addition, the State survey process for HHAs may include review of OASIS data collected versus data encoded and transmitted to the State.
CMS requires that the HHA electronically transmit the accurate, completed, and encoded OASIS data to the State Agency (or CMS contractor) within 30 days of the completion of the assessment (M0090 Date Assessment Completed). Data must be transmitted in a format that meets the requirements specified in the data format standard (i.e., conforming to the CMS standard electronic record layouts, edit specifications, and data dictionary). CMS believes that this time frame for transmitting the data will minimize the burden on the HHA associated with frequency of transmission, maintain uniform assessment reporting time frames, and maintain a clear reporting time frame that eliminates the variation of days in a month. Therefore, HHAs are free to develop schedules for transmitting the data that best suit their needs. HHAs must use CMS-specified electronic communications protocols to contact the State Agency or CMS contractor, transmit the export file, and receive validation information. HHAs required to submit OASIS data must do so using browser software to access the State system via the Medicare Data Communications Network, which provides a direct telephone connection for submission and interim reports. Once transmitted, the State Agency or CMS contractor validates the information while the HHA remains on-line to ensure that some basic elements such as format and HHA information conform to CMS requirements. Once these file checks are completed, a message indicating whether the file has been accepted or rejected is sent back to the HHA's terminal and appears on its computer screen and is reported on the initial validation report displaying all Fatal File and Warning messages in relation to the submission file as a whole. If the submission passes the initial validation check, each individual record is then checked for errors or exceptions to the data specifications, and a Final Validation Report is generated. If the individual record is rejected, a message is sent to the HHA along with the rejected submission file for correction. A file or individual record may be rejected for a variety of reasons, (e.g., the provider identification name or number submitted may be incorrect, the number of records indicated in the trailer record does not match the actual number of records submitted). The HHA must make the corrections and resubmit the file to the State.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Condition of Participation: Comprehensive Assessment of Patients
42 CFR 484.55 requires that a patient receive from the HHA a patient-specific, comprehensive assessment that accurately reflects the patient's current health status and includes information that may be used to demonstrate the patient's progress toward achievement of desired outcomes. The comprehensive assessment must (1) identify the patient's continuing need for home care; (2) meet the patient's medical, nursing, rehabilitative, social, and discharge planning needs; and (3) for Medicare patients, identify eligibility for the home health benefit, including the patient's homebound status. The comprehensive assessment must also incorporate the exact use of the current version of the OASIS data set, which is found on the CMS OASIS web site at HYPERLINK http://www.cms.hhs.Qov/oasis; http://www.cms.hhs.Qov/oasis; click on "Data Set." A comprehensive assessment identifies patient progress toward desired outcomes or goals of the care plan.
CMS expects that HHAs will collect OASIS data in the context of a comprehensive assessment on adult Medicare or Medicaid patients (age 18 or over) receiving skilled health services from the HHA, except for patients receiving care for pre- and post-partum conditions. Patients receiving skilled health services, whose care is reimbursed by other than Medicare or Medicaid, must receive comprehensive assessments, but the collection of OASIS data is not required. For patients receiving only personal care services, regardless of payer source, a comprehensive assessment is also required, but not the collection of OASIS data. Patients who receive poly services such as homemaker, chore, or companion services do not require the comprehensive assessment.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Five standards are contained in the Comprehensive Assessment CoP.
Following are the requirements for each standard.
a. §484.55 Standard: Initial Assessment Visit
The initial visit is performed to determine the immediate care and support needs of the patient. This visit is conducted within 48 hours of referral or within 48 hours of a patient's return home from an inpatient stay, or on the physician-ordered start of care date. The initial assessment visit is intended to ensure that the patient's most critical needs for home care services are identified and met in a timely fashion. For Medicare patients, this initial assessment determines eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be conducted by a registered nurse unless rehabilitation therapy services are the only services ordered by the physician. Under the Medicare home health benefit, any one of three services (skilled nursing, physical therapy, or speech-language pathology) can establish program eligibility. If rehabilitation therapy services are the only services ordered by the physician, the initial assessment may be made by the appropriate rehabilitation skilled professional if the need for that service establishes eligibility for the home health benefit. The law governing home health eligibility prevents occupational therapy from establishing eligibility for the Medicare home health benefit at the initial assessment, though once eligibility is established, then continuing occupational therapy could establish eligibility for a subsequent episode (meaning that the occupational therapist could complete the Recertification assessment). If no skilled service is delivered at this initial assessment, this visit will not be considered the SOC nor is it considered a reimbursable visit for the Medicare home health benefit.
Note that for payers other than Medicare, the occupational therapist may complete the initial assessment if the need for occupational therapy establishes program eligibility.
The comprehensive assessment is not required to be completed at the initial assessment visit, although the HHA may choose to do so. If a skilled service is delivered at the initial assessment visit, thus establishing the SOC, the comprehensive assessment may be initiated at this visit and completed within the time frames discussed below, depending on agency policy.
b. §484.55(b) Standard: Completion of the Comprehensive Assessment
The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than five calendar days after the start of care.
This requirement does not preclude an HHA from completing the comprehensive assessment during the SOC visit, and many HHAs currently operate in such a manner. This time frame provides operational flexibility to the HHA while maintaining patient safety in ensuring that all patient needs will be identified within a standard time period. Some HHAs have policies requiring that a nurse conduct the comprehensive assessment. Home care staff should follow agency policies governing which disciplines can complete the comprehensive assessment.
C. §484.55(c) Standard: Drug Regimen Review
Under this requirement, the comprehensive assessment must include a review of all medications the patient is currently using to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects and drug interactions, duplicate drug therapy, and noncompliance with drug therapy.
While patients receive their drug regimen from the physician, review of this regimen is an integral part of the comprehensive assessment. In addition, this review is an important safeguard for patients who may receive medications from a variety of physicians and pharmacies. Some agencies have policies requiring nurses to do the drug regimen review. In addition, some state practice acts may preclude therapists from completing the drug regimen review. Home care staff should follow state regulations and agency polices governing which disciplines can complete the drug regimen review.
d. §484.55(d) Standard: Update of the Comprehensive Assessment
The comprehensive assessment, which includes OASIS items for Medicare and Medicaid patients, must be updated and revised as frequently as the patient's condition requires, but not less frequently than every 60 days beginning with the start of care date; within 48 hours of the patient's return home from an inpatient facility stay of 24 hours or more for any reason except diagnostic testing; and at discharge. The update of the comprehensive assessment must include completion of all required OASIS items for that time point, plus any others determined necessary by the HHA for a comprehensive assessment. This assessment provides information for determination of changes in treatment or plan of care. Therefore, a comprehensive assessment also is required when there is a major decline or improvement in a patient's health status as defined by the HHA.
An inpatient facility admission as an event is generally a predictor of a change in the patient's health status and therefore should be captured in the OASIS data. In addition, because patients frequently improve rapidly upon returning home from an inpatient facility, it is important for the HHA to assess the patient's true needs as quickly as possible after discharge from the inpatient facility. Therefore, the comprehensive assessment is required within 48 hours of the patient's return to the home from an inpatient facility admission of 24 hours or more for any reason other than diagnostic tests.
Follow-up assessments must be completed every 60 days that a patient is under care. For Medicare and Medicaid patients, when a follow-up assessment is due, it must be completed no earlier than four calendar days before, and no later than the day marking the end of the 60-day period (i.e., day 56 through day 60 of the period).
e. §484.55(e) Standard: Incorporation of the OASIS Data Set
OASIS must be incorporated into the HHAs own assessment, exactly as written. Both the language and the groupings of the OASIS items must be maintained. Integrating the OASIS items into the agency's own assessment system in the sequence presented in the OASIS form would facilitate data entry of the items into data collection and reporting software. However, HHAs may integrate the items in such a way that best Suits the agency's own assessment.
The OASIS data set is not intended to constitute a complete comprehensive assessment instrument. Rather, the data set comprises items that are a necessary part of a complete comprehensive assessment and that are essential to uniformly and consistently measure patient outcomes. An HHA can use the data set as the foundation for valid and reliable information for patient assessment, care planning, service delivery, and improvement efforts.
The OASIS items are already used in one form or another by virtually all HHAs that conduct thorough assessments, and simply adding the OASIS data set to the rest of the HHA's paperwork would be burdensome and duplicative. Therefore, we expect HHAs to replace similar assessment items with OASIS items in their assessment forms to avoid lengthening the assessment unnecessarily. This may be accomplished by modification of existing forms or using commercially available comprehensive assessment forms that include OASIS items. The Mxxxx numbers for each OASIS data item should be retained to allow for easy recognition of the required OASIS item in the HHA comprehensive assessments.
What’s New About the OASIS-C Numbering System.
The OASIS-C represents the most comprehensive revision to OASIS since its original release in 1999. Please note that, with the exception of the tracking items and M0903/M0906, the OASIS-C items have been renumbered; thus the OASIS-B1 M0 item numbers do not correspond to the new OASIS-C numbering scheme.
Table 1: OASIS-C Numbering System.
Patient Tracking Items M0010 - M0069; M0140 – M0150
Clinical RecordsM0080 – M0110
Patient History Diagnoses -M1000s
Living Arrangements-M1100
Sensory Status-M1200s
Integumentary Status-M1300s
Respiratory Status-M1400s
Cardiac Status-M1500s
Elimination Status-M1600s
Neuro/Emotional Behavioral Status -M1700s
ADLs/IADLs-M1800s + M1900s
Medications-M2000s
Care Management-M2100s
Therapy Need and Plan of Care-M2200s
Emergent Care-M2300s
Date Collected at Transfer/Discharge -M2400s, M0903 + M0906
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Time Points
OASIS-C data are collected at the following time points:
Start of Care
Resumption of Care following inpatient facility stay
Recertification within the last five days of each 60-day recertification period
Other Follow-Up
Transfer to inpatient facility
Discharge from home care
Death at home
All of these assessments, with the exception of transfer to inpatient facility and death at home, must be conducted during a home visit because all require the clinician to have an in-person encounter with the patient. The transfer to an inpatient facility requires collection of limited OASIS data (most of which may be obtained through a telephone call).
At the start of care time point, the comprehensive assessment should be completed within five days of the start of care date. At the resumption of care, the comprehensive assessment must be completed within 48 hours of inpatient facility discharge. For the transfer to inpatient facility, discharge from home care, death at home, and other follow-up, the assessments must be completed within 48 hours of becoming aware of the transfer, discharge, death, or significant change in condition.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Who completes OASIS-C?
As identified in (M0080) Discipline of Person Completing Assessment, the comprehensive assessment and OASIS data collection should be conducted by a registered nurse (RN) or any of the therapies (PT, SLP/ST, OT). An LPN/LVN, PTA, OTA, MSW, or Aide may not complete OASIS assessments.
In cases involving nursing, the RN completes the comprehensive assessment at SOC. Any discipline qualified to perform assessments – RN, PT, SLP, OT – may complete subsequent assessments. For a therapy-only case, the therapist usually conducts the comprehensive assessment. It is acceptable for a PT of SLP to conduct and complete the comprehensive assessment at SOC. An OT may conduct and complete the assessment when the need for occupational therapy establishes program eligibility. Note: Occupational therapy alone does not establish for the Medicare home health benefit at the start of care; however, occupational therapy may establish eligibility under other programs, such as Medicaid. The Medicare home health patient who is receiving services from multiple disciplines (i.e., skilled nursing, physical therapy, and occupational therapy) during the episode of care, can retain eligibility if, over time, occupational therapy is only remaining skilled discipline providing care. At that time, an OT can conduct OASIS assessments.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Section 484.20(a) Standard: Encoding OASIS Data
Once the comprehensive assessment has been completed and OASIS data collected, HHAs enter the OASIS information into the computer system, which we call “encoding.” All the time points of the OASIS assessments have a uniform time frame of thirty days from the date the assessment is completed. (M0090 – Date Assessment Completed) for encoding and submitting data. Once the OASIS data are encoded (in software available from CMS or other software that conforms to the CMS standard electronic record layout, edit specifications, and data dictionary), the agency will review each assessment and edit it for transmission to the State Agency. During this preparation period, the HHA must run software application that subjects each patient data set to the CMS edit specifications and makes it transmission –ready. The agency must correct any information that does not pass the CMS specified edits (e.g., data is missing, incorrect, or inconsistent). Staff entering data may need to contact the qualified clinician who assessed the patient for assistance and clinical notes, which document the assessment, are better at a point in time closer to the assessment activity than if the edits and corrections are delayed.
HHAs have flexibility in the method used to encode their data. Data can be encoded directly by the skilled professional who conducts the assessment into a laptop or hand held computer, by a clerical staff member from a hard copy of the completed assessment, or by a data entry operator or service with whom the HHA may contract to enter the data. Any of these acceptable methods of meeting the regulatory reporting requirements for OASIS. However, the HHA is ultimately responsible for meeting the reporting requirements as well as maintaining patient confidentiality.
Non-clinical staff may not assess patients or complete assessment items; however, clerical staff or data entry operators may enter into the computer the OASIS data collected by the skilled professional. In entering the data, HHAs must comply with all requirements for safeguarding the confidentiality of protected health (patient-identifiable) information.
Once the OASIS data are encoded, HHAs use their software to review and edit the data prior to transmission to the State Agency. When editing the data prior to the transmission, it is important to remember that the edits include an electronic safety net to preclude the transmission of erroneous or inconsistent information and enforce he required formatting for the data set items. When transmitted, the patient assessment data are stabilized at the time point of the assessment, preventing the override of current assessment information with future or past information.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Section 484.20(b) Standard: Accuracy of Encoded OASIS Data
The encoded OASIS data must accurately reflect the patient’s status at the time the information is collected. Before transmission, the HHA must ensure that data items on its own clinical record match the encoded data that are sent to the State. We expect that once the qualified skilled professional completes the assessment, the HHA will develop a means to ensure that the OASIS data input into the computer and transmitted to the State Agency (or CMS contractor) exactly reflect the data collected by the skilled professional. Appendix B contains recommendations for conducting data quality audits on a routine basis and includes information from the original OASIS Implementation Manual (Chapter 12). In addition, the State survey process for HHAs may include review of OASIS data collected versus data encoded and transmitted to the State.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Section 484.20(c) Standard: Transmittal of OASIS Data
The encoded OASIS data must accurately reflect the patient’s status at the time the information is collected. Before transmission, the HHA must ensure that data items on its own clinical record match the encoded data that are sent to the State. We expect that once the qualified skilled professional completes the assessment, the HHA will develop a means to ensure that the OASIS data input into the computer and transmitted to the State Agency (or CMS contractor) exactly reflect the data collected by the skilled professional. Appendix B contains recommendations for conducting data quality audits on a routine basis and includes information from the original OASIS Implementation Manual (Chapter 12). In addition, the State survey process for HHAs may include review of OASIS data collected versus data encoded and transmitted to the State.
CMS requires that the HHA electronically transmit the accurate, completed, and encoded OASIS data to the State Agency (or CMS contractor) within 30 days of the completion of the assessment (M0090 Date Assessment Completed). Data must be transmitted in a format that meets the requirements specified in the data format standard (i.e., conforming to the CMS standard electronic record layouts, edit specifications, and data dictionary). CMS believes that this time frame for transmitting the data will minimize the burden on the HHA associated with frequency of transmission, maintain uniform assessment reporting time frames, and maintain a clear reporting time frame that eliminates the variation of days in a month. Therefore, HHAs are free to develop schedules for transmitting the data that best suit their needs. HHAs must use CMS-specified electronic communications protocols to contact the State Agency or CMS contractor, transmit the export file, and receive validation information. HHAs required to submit OASIS data must do so using browser software to access the State system via the Medicare Data Communications Network, which provides a direct telephone connection for submission and interim reports. Once transmitted, the State Agency or CMS contractor validates the information while the HHA remains on-line to ensure that some basic elements such as format and HHA information conform to CMS requirements. Once these file checks are completed, a message indicating whether the file has been accepted or rejected is sent back to the HHA's terminal and appears on its computer screen and is reported on the initial validation report displaying all Fatal File and Warning messages in relation to the submission file as a whole. If the submission passes the initial validation check, each individual record is then checked for errors or exceptions to the data specifications, and a Final Validation Report is generated. If the individual record is rejected, a message is sent to the HHA along with the rejected submission file for correction. A file or individual record may be rejected for a variety of reasons, (e.g., the provider identification name or number submitted may be incorrect, the number of records indicated in the trailer record does not match the actual number of records submitted). The HHA must make the corrections and resubmit the file to the State.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Condition of Participation: Comprehensive Assessment of Patients
42 CFR 484.55 requires that a patient receive from the HHA a patient-specific, comprehensive assessment that accurately reflects the patient's current health status and includes information that may be used to demonstrate the patient's progress toward achievement of desired outcomes. The comprehensive assessment must (1) identify the patient's continuing need for home care; (2) meet the patient's medical, nursing, rehabilitative, social, and discharge planning needs; and (3) for Medicare patients, identify eligibility for the home health benefit, including the patient's homebound status. The comprehensive assessment must also incorporate the exact use of the current version of the OASIS data set, which is found on the CMS OASIS web site at HYPERLINK http://www.cms.hhs.Qov/oasis; http://www.cms.hhs.Qov/oasis; click on "Data Set." A comprehensive assessment identifies patient progress toward desired outcomes or goals of the care plan.
CMS expects that HHAs will collect OASIS data in the context of a comprehensive assessment on adult Medicare or Medicaid patients (age 18 or over) receiving skilled health services from the HHA, except for patients receiving care for pre- and post-partum conditions. Patients receiving skilled health services, whose care is reimbursed by other than Medicare or Medicaid, must receive comprehensive assessments, but the collection of OASIS data is not required. For patients receiving only personal care services, regardless of payer source, a comprehensive assessment is also required, but not the collection of OASIS data. Patients who receive poly services such as homemaker, chore, or companion services do not require the comprehensive assessment.
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades. The OASIS items have been raised several times since 1999 to address the burden of data collection, refine items for payment algorithms, and enhance outcome reporting. The information below are excerpts of pertinent information from the OASIS-C Manual. Please refer to the OASIS-C Manual for complete information.
Five standards are contained in the Comprehensive Assessment CoP.
Following are the requirements for each standard.
a. §484.55 Standard: Initial Assessment Visit
The initial visit is performed to determine the immediate care and support needs of the patient. This visit is conducted within 48 hours of referral or within 48 hours of a patient's return home from an inpatient stay, or on the physician-ordered start of care date. The initial assessment visit is intended to ensure that the patient's most critical needs for home care services are identified and met in a timely fashion. For Medicare patients, this initial assessment determines eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be conducted by a registered nurse unless rehabilitation therapy services are the only services ordered by the physician. Under the Medicare home health benefit, any one of three services (skilled nursing, physical therapy, or speech-language pathology) can establish program eligibility. If rehabilitation therapy services are the only services ordered by the physician, the initial assessment may be made by the appropriate rehabilitation skilled professional if the need for that service establishes eligibility for the home health benefit. The law governing home health eligibility prevents occupational therapy from establishing eligibility for the Medicare home health benefit at the initial assessment, though once eligibility is established, then continuing occupational therapy could establish eligibility for a subsequent episode (meaning that the occupational therapist could complete the Recertification assessment). If no skilled service is delivered at this initial assessment, this visit will not be considered the SOC nor is it considered a reimbursable visit for the Medicare home health benefit.
Note that for payers other than Medicare, the occupational therapist may complete the initial assessment if the need for occupational therapy establishes program eligibility.
The comprehensive assessment is not required to be completed at the initial assessment visit, although the HHA may choose to do so. If a skilled service is delivered at the initial assessment visit, thus establishing the SOC, the comprehensive assessment may be initiated at this visit and completed within the time frames discussed below, depending on agency policy.
b. §484.55(b) Standard: Completion of the Comprehensive Assessment
The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than five calendar days after the start of care.
This requirement does not preclude an HHA from completing the comprehensive assessment during the SOC visit, and many HHAs currently operate in such a manner. This time frame provides operational flexibility to the HHA while maintaining patient safety in ensuring that all patient needs will be identified within a standard time period. Some HHAs have policies requiring that a nurse conduct the comprehensive assessment. Home care staff should follow agency policies governing which disciplines can complete the comprehensive assessment.
C. §484.55(c) Standard: Drug Regimen Review
Under this requirement, the comprehensive assessment must include a review of all medications the patient is currently using to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects and drug interactions, duplicate drug therapy, and noncompliance with drug therapy.
While patients receive their drug regimen from the physician, review of this regimen is an integral part of the comprehensive assessment. In addition, this review is an important safeguard for patients who may receive medications from a variety of physicians and pharmacies. Some agencies have policies requiring nurses to do the drug regimen review. In addition, some state practice acts may preclude therapists from completing the drug regimen review. Home care staff should follow state regulations and agency polices governing which disciplines can complete the drug regimen review.
d. §484.55(d) Standard: Update of the Comprehensive Assessment
The comprehensive assessment, which includes OASIS items for Medicare and Medicaid patients, must be updated and revised as frequently as the patient's condition requires, but not less frequently than every 60 days beginning with the start of care date; within 48 hours of the patient's return home from an inpatient facility stay of 24 hours or more for any reason except diagnostic testing; and at discharge. The update of the comprehensive assessment must include completion of all required OASIS items for that time point, plus any others determined necessary by the HHA for a comprehensive assessment. This assessment provides information for determination of changes in treatment or plan of care. Therefore, a comprehensive assessment also is required when there is a major decline or improvement in a patient's health status as defined by the HHA.
An inpatient facility admission as an event is generally a predictor of a change in the patient's health status and therefore should be captured in the OASIS data. In addition, because patients frequently improve rapidly upon returning home from an inpatient facility, it is important for the HHA to assess the patient's true needs as quickly as possible after discharge from the inpatient facility. Therefore, the comprehensive assessment is required within 48 hours of the patient's return to the home from an inpatient facility admission of 24 hours or more for any reason other than diagnostic tests.
Follow-up assessments must be completed every 60 days that a patient is under care. For Medicare and Medicaid patients, when a follow-up assessment is due, it must be completed no earlier than four calendar days before, and no later than the day marking the end of the 60-day period (i.e., day 56 through day 60 of the period).
e. §484.55(e) Standard: Incorporation of the OASIS Data Set
OASIS must be incorporated into the HHAs own assessment, exactly as written. Both the language and the groupings of the OASIS items must be maintained. Integrating the OASIS items into the agency's own assessment system in the sequence presented in the OASIS form would facilitate data entry of the items into data collection and reporting software. However, HHAs may integrate the items in such a way that best Suits the agency's own assessment.
The OASIS data set is not intended to constitute a complete comprehensive assessment instrument. Rather, the data set comprises items that are a necessary part of a complete comprehensive assessment and that are essential to uniformly and consistently measure patient outcomes. An HHA can use the data set as the foundation for valid and reliable information for patient assessment, care planning, service delivery, and improvement efforts.
The OASIS items are already used in one form or another by virtually all HHAs that conduct thorough assessments, and simply adding the OASIS data set to the rest of the HHA's paperwork would be burdensome and duplicative. Therefore, we expect HHAs to replace similar assessment items with OASIS items in their assessment forms to avoid lengthening the assessment unnecessarily. This may be accomplished by modification of existing forms or using commercially available comprehensive assessment forms that include OASIS items. The Mxxxx numbers for each OASIS data item should be retained to allow for easy recognition of the required OASIS item in the HHA comprehensive assessments.
Tuesday, October 13, 2009
Home Health Compliance Discussion
Compliance issues frequently occur within the home health industry in referral patterns, billing and coding of claims, contractual and joint venture relationships, and licensure of home health professionals. Listed below are a few fact patterns that should be a cause for concern for the Agency compliance officer.
Q: When should the HHA compliance officer think “Stark”?
A: Anytime the HHA has a compensation/referral relationship with a physician. In a recent case, an Agency paid five physicians for services involving review of patients’ charts and plans of care, participation in regular meetings to review and discuss quality of care issues, and participation in training and staff evaluation. This relationship was held to have violated the Stark Law because it was found the physicians had a prohibited compensation arrangement. In the end, the HHA was held liable for approximately $400,000.
Q: When should the HHA compliance officer think “Anti-kickback!”?
A: Anytime there is a potential for giving anything of value for the referral of patients to someone in a position to refer.
Antikickback Example 1:
A HHA provided free medical alert pages and pager monitoring service to homebound patients during the period that they were receiving home health services. The OIG ruled that, while having potential for fraud and abuse, the arrangement did not violate the law, because the devices promoted and improved quality of care.
Antikickback Example 2:
A nation-wide network of HHAs decided to provide prospective customers with a free “preoperative home safety assessment.” This involved having a licensed physical therapist who either made a house call or telephoned the patient and reviewed with the patient whether the home was suitable for postoperative recovery. The OIG ruled that the assessment was something of value given to the patient which was used to solicit business, and the arrangement therefore violated the Anti-kickback Statute.
Q: When should the HHA compliance officer think “False Claim”?
A: Anytime the facts indicate that a false claim was “knowingly” submitted to the government. In a Department of Justice Press Release on February 9th, 2006, Intrepid USA, a chain of some 150 HHAs, paid an $8 million settlement with the government for submitting false claims to federal healthcare programs “where services had not been provided by a qualified person, where Intrepid had failed to complete and maintain the necessary documentation to support its claims, or where the company had otherwise violated Medicare’s regulations.”
Q: License credentialing. How important is it? When should the HHA compliance officer be on “licensing lookout”?
A: Tenet Hospital in Florida paid a settlement of some $29 million for alleged violations of the False Claims Act, including home health services provided by HHAs based on fraudulent statements or omissions regarding the patient’s medical records, condition, history, or eligibility for medical coverage. Services that were provided by unskilled, unlicensed, or uncertified personnel, or were never ordered by a physician may result in a false claim.
The Parrella Blog thanks Gregory M. Nowakowski
Of Rogers Mantese & Associates, P.C. for his permission to use excerpts of their previously authored article in the HCCA journal.
Q: When should the HHA compliance officer think “Stark”?
A: Anytime the HHA has a compensation/referral relationship with a physician. In a recent case, an Agency paid five physicians for services involving review of patients’ charts and plans of care, participation in regular meetings to review and discuss quality of care issues, and participation in training and staff evaluation. This relationship was held to have violated the Stark Law because it was found the physicians had a prohibited compensation arrangement. In the end, the HHA was held liable for approximately $400,000.
Q: When should the HHA compliance officer think “Anti-kickback!”?
A: Anytime there is a potential for giving anything of value for the referral of patients to someone in a position to refer.
Antikickback Example 1:
A HHA provided free medical alert pages and pager monitoring service to homebound patients during the period that they were receiving home health services. The OIG ruled that, while having potential for fraud and abuse, the arrangement did not violate the law, because the devices promoted and improved quality of care.
Antikickback Example 2:
A nation-wide network of HHAs decided to provide prospective customers with a free “preoperative home safety assessment.” This involved having a licensed physical therapist who either made a house call or telephoned the patient and reviewed with the patient whether the home was suitable for postoperative recovery. The OIG ruled that the assessment was something of value given to the patient which was used to solicit business, and the arrangement therefore violated the Anti-kickback Statute.
Q: When should the HHA compliance officer think “False Claim”?
A: Anytime the facts indicate that a false claim was “knowingly” submitted to the government. In a Department of Justice Press Release on February 9th, 2006, Intrepid USA, a chain of some 150 HHAs, paid an $8 million settlement with the government for submitting false claims to federal healthcare programs “where services had not been provided by a qualified person, where Intrepid had failed to complete and maintain the necessary documentation to support its claims, or where the company had otherwise violated Medicare’s regulations.”
Q: License credentialing. How important is it? When should the HHA compliance officer be on “licensing lookout”?
A: Tenet Hospital in Florida paid a settlement of some $29 million for alleged violations of the False Claims Act, including home health services provided by HHAs based on fraudulent statements or omissions regarding the patient’s medical records, condition, history, or eligibility for medical coverage. Services that were provided by unskilled, unlicensed, or uncertified personnel, or were never ordered by a physician may result in a false claim.
The Parrella Blog thanks Gregory M. Nowakowski
Of Rogers Mantese & Associates, P.C. for his permission to use excerpts of their previously authored article in the HCCA journal.
Tuesday, September 29, 2009
Revisions to Claims Processing Instructions for Osteoporosis Drugs under the Home Health Benefit
Effective 01/01/2010, the date of service on claims submitted for osteoporosis drugs must fall within the start and end dates of an existing home health prospective payment system (PPS) episode.
PGBA-RHHI adds ICD-9 codes for PT
PGBA-RHHI has added the following ICD-9 codes to support Physical Therapy for Home Health (LCD 99HH-021-L): 359.71, 359.78, 832.2 (effective 10/01/09) v15.88 (effective 09/17/09).
Monday, September 21, 2009
Falls Evaluation
Falls Evaluations are components of existing quality improvement efforts for Medicare Part A providers.
Palmetto GBA has included V15.88 (history of falls) in the final policy to reflect this potential. While claims containing V15.88 would still require the addition of another covered ICD-9-CM code to specify the impairment of structure/function and/or activity limitation (e.q., ICD-9-CM 438.4 monoplegia of lower limb; ICD-9-CM 781.2 abnormality of gait), inclusion of the V15.88 code will help communicate the coverage available and help promote communication of reasonable and necessary physical therapy and/or occupational therapy interventions.
Palmetto GBA has included V15.88 (history of falls) in the final policy to reflect this potential. While claims containing V15.88 would still require the addition of another covered ICD-9-CM code to specify the impairment of structure/function and/or activity limitation (e.q., ICD-9-CM 438.4 monoplegia of lower limb; ICD-9-CM 781.2 abnormality of gait), inclusion of the V15.88 code will help communicate the coverage available and help promote communication of reasonable and necessary physical therapy and/or occupational therapy interventions.
Monday, August 31, 2009
Changes to Outlier Payment Policies
Home health agencies (HHAs) receive additional payments (outlier payments) for 60-day home health episodes of care that carry unusually high costs. CMS, in a recently proposed rule, is seeking to cap outlier payments at 10 percent per agency and target total aggregate outlier payment at 2.5 percent of total HH PPS payments. Currently, the target for outlier payment targets is 5 percent of total HH PPS payments. As such, CMS reduces home health rates by 5 percent to fund outlier payments. By lowering the total outlier payment target to 2.5 percent of total HH PPS payments, CMS would increase home health rates by 2.5 percent.
Monday, August 17, 2009
Final Percentage Payment Reminder
The Plan of Care (Form 485) must be signed and dated by a physician before the claim for each episode for services is submitted for the final percentage payment.
Initial Percentage Payment Reminder
If a physician signed Plan of Care (Form 485) is not available at the beginning of the episode, the HHA may submit a RAP for the initial percentage payment based on a physician’s verbal orders OR a referral prescribing detailed orders for the services to be rendered that is signed and dated by the physician. A billable visit must be rendered prior to the submission of a RAP.
DME as covered service by a Home Health Agency
DME must be differentiated from routine and non-routine medical supplies which are bundled to the agency and included in the base rate payment. Durable Medical Equipment (DME) is paid separately from the PPS bundled rate and is excluded from consolidated billing requirements governing PPS. The determining factor is the medical classification of the supply, not the diagnosis of the patient.
Friday, July 17, 2009
CMS NEWS RELEASE
Some payments for home health providers received by the Centers for Medicare & Medicaid Services (CMS) Healthcare Integrated Ledger Accounting System (HIGLAS) for processing for cycle dates from July 7, 2009 through July 9, 2009, may have been paid incorrectly due to the installation of the July release. Home health Request for Anticipated Payment (RAP) and Low Utilization Payment Adjustment (LUPA) claims and adjustments where the original or adjustment amount ended in zeroes were truncated, and the zeroes were dropped from the payment calculation. This has resulted in underpayments and some overpayments on claims processing for payment. The problem has been identified and was corrected on July 11, 2009 to prevent future occurrences.
Claims that were placed in the approved to pay location prior to the installation of the fix will pay at the incorrect amount. All future claims will be paid correctly. CMS is aggressively working to identify and calculate the payment differences on all impacted claims. A process to issue payments to providers is being developed by CMS with the highest priority, with an expected completion date on or about July 31, 2009. The corrected payments for the home health original claim underpayments will be issued on or about July 20, 2009, followed by corrected payments for the adjusted claim differences on or about July 31, 2009.
Impact to Providers
All amounts due will be issued as non-claim payments and appear with your normal remittance advice. Some claims on payments during the timeframe referenced above were underpaid and some adjustments were overpaid. The claim details related to these claim payments will be reported correctly within the remit, however, the payment difference will appear in the ‘Adjust to Balance’ field. There is no action required by providers regarding this issue, since CMS will be issuing corrected payments to all impacted providers.
Claims that were placed in the approved to pay location prior to the installation of the fix will pay at the incorrect amount. All future claims will be paid correctly. CMS is aggressively working to identify and calculate the payment differences on all impacted claims. A process to issue payments to providers is being developed by CMS with the highest priority, with an expected completion date on or about July 31, 2009. The corrected payments for the home health original claim underpayments will be issued on or about July 20, 2009, followed by corrected payments for the adjusted claim differences on or about July 31, 2009.
Impact to Providers
All amounts due will be issued as non-claim payments and appear with your normal remittance advice. Some claims on payments during the timeframe referenced above were underpaid and some adjustments were overpaid. The claim details related to these claim payments will be reported correctly within the remit, however, the payment difference will appear in the ‘Adjust to Balance’ field. There is no action required by providers regarding this issue, since CMS will be issuing corrected payments to all impacted providers.
Tuesday, July 14, 2009
OASIS – C Posted for Review
Draft OASIS-C has been posted by CMS for review. The final version of the new OASIS-C is expected within the next few months with a roll-out date of January, 2010. CMS expects the OASIS User’s Manual to be updated in September, 2009 and will contain detailed guidance on the use of OASIS-C.
Non-Clinician and Patient’s First Home Health Visit
If nursing services are ordered, federal regulations require the initial assessment visit to be performed by an RN and to be performed by a qualified therapist if services other than nursing services are ordered. Therefore, a non-clinician is prohibited by federal law from visiting the patient to collect patient identifying OASIS information regardless of the home health services ordered.
Wednesday, May 13, 2009
CMS Corrects Edit of HIPPS Codes for Home Health Claims
With an implementation date of 10/05/09, CMS created a payment safeguard that ensures home health agencies no longer incorrectly change the supply severity level reflected in the 5th position of Home Health Prospective Payment System (HH PPS) Health Insurance Prospective Payment System (HIPPS) codes. The fifth position of the HIPPS on the final claim can only differ from the fifth position of that code on the Request for Anticipated Payment (RAP) in cases where supplies were initially expected to be required, but were not supplied. Then, the code can only change from the S-X letter code on the RAP to its correspondence number (1-6) code on the final claim.
HHAs should change the fifth position of the HIPPS code on HH PPS claims only in order to report cases where supplies were or were not provided during the episode.
Tuesday, April 14, 2009
Home health prospective payment system
On 01/01/09, CMS updated the 60 day national episode rates and the national per-visit amounts under the home health prospective payment system (HH PPS). Medicare home health payments for HHAs that report quality data will be increased by 2.9%, while payments for those HHAs that do not report quality data will be increased 0.9%. For more information on how to receive your 2.9% increase for reporting quality data, please call your RHHI at 866-801-5301.
Stamp signatures no longer be accepted
Effective with dates of service beginning April 28th, 2008 stamp signatures will no longer be accepted as a valid physician’s signature for home health orders, including the plan of care. Claims with physician stamp signatures will be denied during the medical review process.
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