home health regulatory review · 2018-10-05 · registration materials o abt associates will...

12/16/2015

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Home Health Regulatory Review

Presented by:

Deanna Loftus

HEALTHCAREfirst Director of Regulatory Compliance

Mary St. Pierre, RN, BSN, MGA

HEALTHCAREfirst Consultant / Industry Expert

December 2015

Webinar Agenda

• Medicare Administrative Contractors

• Important Billing Reminders

• Discharge Planning Proposed Rule

• 2016 PPS Final Rule/Payment Update

• In-depth look at Proposed VBP Pilot Program

• Upcoming Changes and Mandates

• HETS Eligibility Transition Update

• HH Proposed CoPs

Home Health Regulatory ReviewCopyright @ 2015 HEALTHCAREfirst, All Rights Reserved. Recorded December 9, 2015

12/16/2015

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Stay in Tune With Your MAC

http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-

Contractors/Downloads/HomeHealthHospice_JurisdictionMap_OCT2013.pdf

Palmetto GBA

http://www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Home%20Health%20and%20Hospice~Articles~Claims%20Processing%20Issues%20Log?


http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/HomeHealthHospice_JurisdictionMap_OCT2013.pdf







http://www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction 11 Home Health and Hospice~Articles~Claims Processing Issues Log?

http://www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction 11 Home Health and Hospice~Articles~Claims Processing Issues Log?

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National Government Services (NGS)

CGS Administrators

http://www.cgsmedicare.com/hhh/claims/FISS_Claims_Processing_Issues.html


http://www.cgsmedicare.com/hhh/claims/FISS_Claims_Processing_Issues.html

12/16/2015

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Important Billing Reminders

New G Codes Effective January 1, 2016

• Effective for Homecare and Hospice visits with dates of

service 1/1/2016 and after, G0154 will be retired and

replaced with two new codes:

• G0299: Direct skilled nursing services of a registered

nurse (RN) in the home health or hospice setting.

• G0300: Direct skilled nursing of a licensed practical

nurse (LPN) in the home health or hospice setting

https://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/Downloads/R3378CP.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-

MLN/MLNMattersArticles/Downloads/MM9369.pdf


https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3378CP.pdf







https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9369.pdf












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New G Codes Effective January 1, 2016

• Impact to providers: Depending on hospice software

settings, providers may need to update their RN and LPN

profiles/settings within their software in advance of 1/1:

• Hospice: Codes will flow to bills and be used to

determine and if the new Service Intensity Add On

amount applies and calculate it correctly when it does.

• Homecare: Codes will flow to bills

• No changes to G0162, G0163 or G0164

ICD-10 and Initial Encounters

• New guidance permits HHAs to assign “initial

encounters” in the 7th character for certain diagnosis

codes

• Effective January 1, 2016, the HHPPS Grouper logic will

be revised to award points for certain initial encounter

codes based upon the revised ICD-10-CM coding

guidelines for M0090 dates on or after October 1, 2015.

• HHA’s should review their OASIS records and claims

submitted between October 1, 2015, and December 31,

2015, to determine if they should submit a modification

of their assessment and adjust their claim with a revised

HIPPS code.

•


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Discharge Planning

Proposed Rule

http://www.gpo.gov/fdsys/pkg/FR-2015-11-03/pdf/2015-27840.pdf

Discharge Planning

• CMS is proposing two new CoP standards:

• Discharge planning process

• Discharge or transfer summary content

• Discharge Planning summary:

http://w2.healthcarefirst.com/revisions-to-requirements-

for-discharge-planning/












http://w2.healthcarefirst.com/revisions-to-requirements-for-discharge-planning/













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Submitting Comments

• When commenting, refer to file code CMS-3317-P for

Medicare.

• To be assured consideration, comments must be received at

one of the addresses provided below, no later than 5 p.m. on

January 4, 2016.

• Two of the four ways to submit comments are:

o Electronically at http://www.regulations.gov. Follow the

instructions under the "More Search Options“ tab.

o By regular mail using the following address: Centers for

Medicare & Medicaid Services, Department of Health and

Human Services, Attention: CMS-3317-P, P.O. Box 8016,

Baltimore, MD 21244-8016.

2016 HH PPS

Proposed Rule


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HomeHealthPPS/Home-Health-Prospective-Payment-

System-Regulations-and-Notices-Items/CMS-1625-F.html

https://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/Downloads/R3383CP.pdf


http://www.regulations.gov/











https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-and-Notices-Items/CMS-1625-F.html




































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2015 vs. 2016 Payment Rates

Effective for episodes ending on or after January 1, 2016:

Calculation Method:

((2015 rate of $2961.38) x (1.0011 wage index BNAF) x (1.0187 case mix weight adjustment budget neutrality factor) x (.9903 case mix adjustment) – ($80.95 rebasing adjustment) x (1.019 market basket update)) = CY 2016 Rate

2015 Base Rate / Rural Base Rate 2016 Base Rate / Rural Base Rate (Final)

$2,961.38/ $2990.47 $2,965.12/ $2,994.13

2016 Payment Rates

• Overall Impact Estimated at -260 Million (-1.4%)

– 1.9% Increase in the HH payment percentage

– 2.5% decrease in payments from rebasing adjustments

– 0.97% decrease in the standard 60 day episode amount.

• CMS is decreasing the national, standardized 60-day episode payment amount by .97% in CY 2016, 2017 and 2018.

• Recalibration of the HH PPS Case-Mix Weights

• Updates to Reflect Case-Mix Growth

• REMINDER: Sequestration is still in effect


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2015 vs. 2016 Discipline Rates

Discipline 2015 Non-Rural / Rural 2016 Non-Rural / Rural (Final)

HHA $57.89 / $58.45 $60.87/ $61.47

MSS $204.91 / $206.92 $215.47 / $217.58

OT $140.70 / $142.09 $147.95 / $149.40

PT $139.75 / $141.13 $146.95 / $148.39

SN $127.83 / $129.09 $134.42 / $135.74

SLP $151.88 / $153.37 $159.71 / $161.28

*note a 2% reduction to these rates when not submitting quality data

2015 vs. 2016 Supply Rates

Non-Routine Supply Rates (NRS)

*note a 2% reduction to these rates when not

submitting quality data

Severity Level

2015 Non-Rural / Rural 2016 Non-Rural / Rural (Final)

1 $14.36 / $14.50 $14.22 / $14.65

2 $51.86 / $52.37 $51.35 / $52.89

3 $142.19 / $143.60 $140.80 / $145.02

4 $211.25 / $213.35 $209.18 / $215.46

5 $325.76 / $329.00 $322.57/ $332.24

6 $560.27 / $565.85 $554.79 / $571.42


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LUPA Rates

LUPA Add-On Rates

http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html?redirect=/center/hha.asp

*note a 2% reduction to these rates when not submitting quality data

Non-Rural / Rural

SN – 1.8451 PT – 1.6700 SLP – 1.6266

Increase Threshold for Quality Reporting Program

• Current HHQRP currently requires HHAs to submit

70% of OASIS quality assessments (CY 2015 Final

Rule)

• It is important to note that submitting OASIS is

a condition of participation and providers should

make every effort to submit ALL OASIS.

• CMS is increasing the threshold to 80% for OASIS

submission

How are you tracking your OASIS Submissions?


















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New Quality Measure

• Percent of Residents or Patients with Pressure

Ulcers That Are New or Worsened (Short Stay)

(NQF #0678)

• Will be collected using OASIS items

• M1308 (Current Number of Unhealed Pressure

Ulcers at Each Stage or Unstageable)

• M1309 (Worsening in Pressure Ulcer Status

Since SOC/ROC)

Technical Regulations Text Changes

• Technical regulations text changes at §409,

§424, and §484 including:

o Reduction in the outlier pool to 2.5 percent

o The 10% outlier payment cap

o Frequency in review of the plan of care

o Definition of intervening events in calculating

partial episode payment adjustments


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o Clarifying nominal case mix payment

reductions

o Eliminating references to outdated market

basket index factors

o Clarifying the difference between a LUPA

add-on and the LUPA add-on factor and

deleting text referring to the phase -in of the

original prospective payment system.

CMS Encourages EHR Adoption

HHAs are not currently eligible to receive federal

incentives for meaningful use of EHRs and health IT

systems.

o "We encourage stakeholders to utilize health

information exchange and certified health IT to

effectively and efficiently help providers improve

internal care delivery practices, engage patients in

their care, support management of care across the

continuum, enable the reporting of electronically

specified clinical quality measures, and improve

efficiencies and reduce unnecessary costs."


12/16/2015

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Proposed Value Based

Purchasing Pilot Program

Presented by: Mary St. Pierre RN, BSN, MGA


HHVBP Final Rule

• Final rule

o Final rule published: November 5, 2015

o http://www.gpo.gov/fdsys/pkg/FR-2015-11-

05/pdf/2015-27931.pdf

• Implement a HH Value-Based Purchasing (HHVBP)

Model: beginning January 1, 2016

o All Medicare-certified HHAs in selected states

o Participation required

o Data reporting mandated

o Scoring methodology defined

o Payment adjustments and methodology specified













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HHVBP: Overview

• Five performance years

• Intended results

o Incentivize HHAs: better care/greater efficiency

o Study new measure in home health setting

o Enhance public reporting processes

• Modeled after

o Hospital VBP

o HH P4P Demonstration

• Quality measures

o Aligned with National Quality Strategy (NQS) priorities

HHVBP Process

• Assess performance & Adjust payment

• Performance reporting years:

o First year: 2016

o Final year: 2020 (unless modified through later rule)

• Payment adjustment years (up or down)

o CY 2018: 3%

o CY 2019: 5%

o CY 2020: 6%

o CY 2021: 7%

o CY 2022: 8%


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Reports

• Quarterly performance report

• Annual payment adjustment reports

• Annual publicly available performance reports

HHVBP Model Plan

• Evaluate agencies’ performance for care to Medicare

beneficiaries

o Achievement

o Improvement

• Initially: Starter set selected for year one

o Quality measures

OASIS

CWF

CAHPS

o New Measures

• Future: additional measures based on IMPACT Act


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HHVBP Model Framework

• Six NQS Priorities into Four HHVBP Measure

Classifications:

o Classification I: Clinical Quality of Care

o Classification II: Care Coordination and Efficiency

o Classification III: Person/Caregiver-Centered

Experience

o Classification IV: New Measures

Applicable Measures

• Applicable measure

o Measure for which the competing HHA has

provided 20 home health episodes of care per

year.

• Benchmark

o Top decile of HHA performance on specified quality

measure during the baseline period

o Calculated separately for larger volume and

smaller-volume cohorts in state


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Minimum Number of Cases

• HHVPB participation mandatory

o Total points calculation based on measures reported

o New measure reporting required

• No score for Outcome & Clinical Quality measure

o 20 or fewer episodes per year

• No payment adjustment (except 10% New Measure

adjustment)

o If no score for 5 or more of quality measures

Clinical Quality of Care

Care Coordination & Efficiency

Person and Caregiver-Centered Experience

Final Measure Selection

• Measures 2016

o 6 Process

o 10 Outcome

o 5 HHCAHPS

o 3 New

• Future Measures in 2017 per IMPACT Act


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Performance Benchmarks & Thresholds

• Achievement Points and Improvement Points

o By cohort (Large/Small)

o For each measure

o Based on

Achievement scale between threshold and

benchmark

• Threshold: median of HHA’s performance

during baseline period

• Benchmark as top decile of all HHAs’

performance

Improvement: Points along improvement range

of change during performance period and

baseline period

Performance Scoring Methodology

• Performance scoring methodology (20 or more

episodes)

o Determine performance standards (benchmarks

and thresholds) using the 2015 baseline quality

data

o Score HHAs based on their achievement and/or

improvement for each measure

o Weight each classification by the number of

measures employed


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Measure Weighting & Scoring Method

• Weighting

o New Measures:

Based on reporting

Account for 10% of total score

o Outcome, Process, HHCAHPS measures will be:

Account for 90% of total score

Weighted the same

At individual measure level (not classification)

o Rationale:

Varying needs of individual agency populations

Promote improvement for all, not just higher

weighted measures

Achievement Scoring

• Achievement Scoring

o Performance equal to or higher than benchmark

Maximum 10 points

o Performance equal to or greater than performance

threshold but lower than benchmark

1-9 points

o Performance less than achievement threshold

O points


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Improvement Scoring

• Performance equal to or higher than the benchmark

score

o Maximum 10 points

• Performance greater than baseline period score but

below the benchmark

o 0–10 points if within the improvement range

o 0 points if equal to or lower than baseline period

score

Total Performance Scoring

• Using higher of an HHAs achievement or improvement

scores for each measure

o Rounded up or down to the third decimal

o Quarterly basis


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Performance Scoring

• Total Performance Score

o Numeric score ranging from 0 to 100 awarded to

each competing HHA based on its performance

Starter set: quality measures (20 or more

episodes)

• 90% of the TPS equal weight to all

measures in

• Clinical quality of care

• Care Coordination and efficiency

• Person and Caregiver centered

experience

New measures

• 10% equal weight to

Payment Adjustment Methodology

• §484.325 Payment Adjustment

o CMS will determine a payment adjustment up to

the maximum applicable percentage

Upward or downward

For each competing home health agency

Based on the agency’s Total Performance

Score

Using a linear exchange function

Adjustments will be calculated as a percentage

of otherwise applicable payments for home

health


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Payment Adjustment

• Adjustment to maximum applicable percentage for

year

o Using Linear Exchange Function (LEF)

e.g. Slope of LEF for CY 2016: estimated

aggregate value-based payment adjustments

equal to 3-percent of the estimated aggregate

base operating episode payment amount for

CY 2018

o Up or down to 3%

o Based on Total Performance Score (TPS)

o Calculate percentage of HH payments

o Multiply HH Prospective Payment final claim

payment by payment adjustment percentage

Preview & Recalculation Requests

• Quarterly Performance Report

o Notify HHA of quarterly performance on quality measures

30 day preview by HHA

Submit request for recalculation and specific basis

for recalculation if disagree

• Annual TPS and payment adjustment report

o Notify in August in August previous year

30 day preview by HHA

Submit request for recalculation and specific basis

for recalculation if disagree

• Review by CMS for approval or denial of request

o As soon as administratively possible

o Appeals in accord with process under development


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Clinical Quality of Care Measures

• Outcomes

o Improvement ambulation (M1860)

o Improvement transfer (M1850)

o Improvement bathing (M1830)

o Improvement dyspnea (M1400)

• Process

o Drug education on all medication provided to

patient/caregiver during an episode of care (2015)

Communication/Care Coordination

• Outcome

o Discharge to community (M2420)

• Process

o Care management: Types & sources of assistance

(M2102)


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Efficiency and Cost Reduction

• Outcome

o Acute care hospital unplanned during first 60 days

(CCW)

o Emergency department w/o hospitalization (CCW)

Patient Safety

• Outcome

o Improvement pain (M1242)

o Improvement management of oral meds (M2020)

o Prior function ADL/IADL (M1900)


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Population/Community Health

• Process

o Influenza data collected (M1041)

o Influenza immunization received season (M1046)

o Pneumococcal vaccine ever received (M10510

o Reason pneumococcal not received (m1056)

Patient & Caregiver Experience

• CAHPS Outcome (Q 2, 3, 4, 5, 9, 10, 12, 13, 14, 15,

16, 17, 18, 19, 22, 23, 24)

o Care of Patients

o Communication between provider/patients

o Specific care issues

o Global type measures

Overall rating HHA

Willingness to recommend HHA


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Home Health Agency Goals

• Delivery Quality Care through

o Application of standards of practice to yield

Compliance

Better outcomes

Client/caregiver satisfaction

Competitive position in the community

Compensation

Key to Improvement: The Nursing Process

• The Process: Not the Task

o Assess

o Identify needs

o Establish goals

o Plan interventions

o Coordinate with team/physician

o Deliver care

o Reassess and Revise


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The Key: Nursing Process

• Basic rule: Understand the multifaceted,

compounding nature of care failure

• Failure to address medication management leads to:

o Increased pathology, uncontrolled symptoms

Overlooked effectiveness failure, side effects,

drug interactions

• Dyspnea

• Elevated BP, blood sugar

• Weakness

• Pain

o Emergency department use and hospitalization

o Patient/caregiver dissatisfaction

The Key: Nursing Process

• Basic Rule: Understand the multifaceted

compounding nature of care failure

• Failure to address underlying pathology/needs leads

to

o Increased weakness and pain, lead to

Stabilization or Decline in

• Ambulation

• Transfer

• Bathing

o Decline in ambulation, transfer, bathing lead to

Emergency Department Use and

Hospitalization

Patient/caregiver dissatisfaction


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Back to the Basics: Improvement Considerations

• Key Considerations in Care Delivery

o Formal Care Management program

o Training: accurate and comprehensive

assessments

o Plan of care aligned to assessment

o Comprehensive clinical actions (process, not task)

o Regular, scheduled interdisciplinary meetings (in

person or virtual)

o Consistency in assignments/scheduling

o Accountability for patient goal management

o Continuous care: assessment, goal and plan

modification

Back to the Basics: Improvement Considerations

• Analyze outcome reports

• Employ best practices

• Identify clinicians with best outcomes

o Identify care delivery practices

o Apply agency-wide

• Establish coordination processes

• Require physician communication, collaboration and

coordination


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New Measures

• Submission via Web-based platform

o Serves to collect and distribute information from &

to HHAs

• New measures to be reported

o Population/Community Health

Influenza vaccine HHA personnel

Herpes zoster vaccine: patients

o Communication and Coordination

Advance care plan (Patient’s desires if

recovery improbable)

New Measure: Advance Care Planning

• Percentage of patients aged 65 years and older with medical

record documentation that

o Have an advance care plan or surrogate decision maker, or

o Advance care plan was discussed. but patient

Did not wish, or

Was not able to name a surrogate decision maker or

provide an advance care plan

o Data Reporting beginning 10/7/16

For period July 2016 through September 2016

Quarterly thereafter

o Numerator: Number of patients 65 and older that have an

advance care plan or surrogate decision maker

o Denominator: Number of patients 65 and older admitted by

agency


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Influenza Vaccine Coverage for Personnel

• Data Reporting

o Begin no later than 10/7/16 and quarterly thereafter

o For period July 2016 through September 2016

o Numerator by category: number of personnel who:

Received vaccine by agency or other (written

report), or

Medical contraindication, or

Declined/Unknown status, or

Don’t meet definition

o Denominator: Number who work at least one day

October 1 through March 31 separately by category

Employee

Independent practitioner (contractor)

Student/Trainee/Volunteer)

Herpes Zoster Vaccine for Patients

• Data Reporting

o Begin no later than 10/7/16 and quarterly

thereafter

o For period July 2016 through September 2016

• Numerator: total number of Medicare beneficiaries

aged 60 and over who report having ever received

herpes zoster vaccine during the HH episode of care

• Denominator: total number of Medicare beneficiaries

aged 60 and over receiving services


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Future Cross-Setting Measures

• IMPACT Act Requirement

• Timeline January 1, 2017

o Measures to reflect all-condition risk-adjusted potentially

preventable hospital readmission rates

o Resource Use (to include total estimated Medicare

spending per beneficiary)

Payment Standardized Medicare Spending Per

Beneficiary (MSPB)

o Discharge to community

Percentage residents/patients at discharge

assessment who discharged to a higher level of

care versus to the community

o Medication Reconciliation Measure

Percent of patients for whom any needed

medication review actions were completed

Step Into Action

• First Step : Obtain a User Account on the CMS Secure

Portal

o Contact CMS Enterprise Identity Management

(EIDM)website: https://portal.cms.gov/wps/portal/unauthpo

rtal/home/.

• More information

o https://innovation.cms.gov/initiatives/home-health-value-

based-purchasing-model or contact the HHVBP Help

Desk [email protected].

• Questions

o Helpdesk (844) 280-5628 or email

[email protected]


https://portal.cms.gov/wps/portal/unauthportal/home/

https://portal.cms.gov/wps/portal/unauthportal/home/

https://innovation.cms.gov/initiatives/home-health-value-based-purchasing-model











mailto:[email protected]



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Registration

• CMS HHVPB Contractors

o The Lewin Group: portal registration, training and

materials

o Abt Associates will calculate scores, evaluate case

mix, volume measures, etc.

o Evaluation contractor is hired undetermined

• Each HHA must send an email to the help desk at

[email protected] with the name and

contact information for their agency’s point of contact.

This should be someone familiar with the HHA’s day-

to-day operations and has authority to delegate

assignments and tasks.

Registration

• Point of contact must be registered in CMS’ Enterprise

Identity Management System (EIDM) for every specific CCM.

• Other HHA staff involved with VBP will need to register to

access information in the portal. Details will be provided in a

separate webinar on how to register.

• If the HHA’s point of contact leaves, the HHA needs to send

an email [email protected]. CMS will then

follow up to provide instructions for registering a new contact.

• FAQs will be provided, along with future webinars with

Innovation Center Portal training and HHVBP portal training.




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Changes / Mandates

On the Horizon

Changes That Impact Both HH and Hospice

REMINDER: CMS is in the process of terminating all eligibility systems other than the HETS 270/271

• PPTN and VPIQ

o Multi Carrier System (MSC) – Discontinued April 2013

o ViPS Medicare System (VMS) - Discontinued April 2013

• FISS/DDE

o HIQA/HIQH – Currently still active

o ELGH/ELGA – Currently still active

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1249.pdf














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Proposed Conditions of Participation

• http://w2.healthcarefirst.com/home-health-conditions-of-participation-webinar-recording/

• http://www.gpo.gov/fdsys/pkg/FR-2014-10-09/pdf/2014-23895.pdf

• http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-10-06-2.html

Stay in the Loop

www.healthcarefirst.com/blog




























http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-10-06-2.html


















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Thank you!

For the latest Regulatory News & Updates,

visit HEALTHCAREfirst’s Home Health & Hospice Blog

www.healthcarefirst.com

For more information about HEALTHCAREfirst,

please visit our website or call 800.841.6095


home health regulatory review · 2018-10-05 · registration materials o abt associates will...

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