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12/7/2015
1
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
Stay in Tune With Your MAC
http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-
Contractors/Downloads/HomeHealthHospice_JurisdictionMap_OCT2013.pdf
12/7/2015
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Palmetto GBA
http://www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Home%20Health%20and%20Hospice~Articles~Claims%20Processing%20Issues%20Log?
National Government Services (NGS)
CGS Administrators
http://www.cgsmedicare.com/hhh/claims/FISS_Claims_Processing_Issues.html
12/7/2015
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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
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
12/7/2015
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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.
•
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/
12/7/2015
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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
http://www.gpo.gov/fdsys/pkg/FR-2015-11-05/pdf/2015-27931.pdf
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
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
12/7/2015
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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
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?
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)
12/7/2015
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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
Technical Regulations Text Changes
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."
12/7/2015
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Proposed Value Based
Purchasing Pilot Program
Presented by: Mary St. Pierre RN, BSN, MGA
Technical Regulations Text Changes
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
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
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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%
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
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
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Final Measure Selection
• Measures 2016
o 6 Process
o 10 Outcome
o 5 HHCAHPS
o 3 New
• Future Measures in 2017 per IMPACT Act
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
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
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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
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
12/7/2015
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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
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)
12/7/2015
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Communication/Care Coordination
• Outcome
o Discharge to community (M2420)
• Process
o Care management: Types & sources of assistance
(M2102)
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)
12/7/2015
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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
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
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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
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
12/7/2015
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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
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)
12/7/2015
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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
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
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.
12/7/2015
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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.
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
12/7/2015
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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
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
