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12/18/2019
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2020 IS NOT JUST ABOUT PDGM!
Presenter: Melinda A. Gaboury, COS-CHealthcare Provider Solutions, Inc.pdgmimpact.com
AGENDA
OASIS-D1
iQIES
Medicare Beneficiary Identifiers (MBI)
Home Health Final Rule 2020, including PDGM
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ACCURATE OASIS-D1New OASIS-D1 Items
The calculation of the 432 Case-Mix Groupings under the PDGM reflects that the Functional portion of the calculation will include M1800 (Grooming) & M1033 (Risk for Hospitalization). The current OASIS-D data set does not include these two items on the Follow-Up/Recertification (FU) OASIS. Therefore, the following OASIS items have to be collected at the time of FU prior to the PDGM implementation:
•M1033: Risk for Hospitalization•M1800: Grooming
Optional OASIS-D1 Items Several OASIS-D1 items are not required in the case-mix calculation under
PDGM. As a result, CMS now regards 23 current OASIS items as optional for specific time points. (BE CAREFUL – IF YOU HAVE MEDICARE ADVANTAGE PAYERS THAT STILL REQUIRE A PPS HIPPS CODE YOU WILL NEED TO COMPLETE OASIS ITEMS ACCORDINGLY!)
For OASIS-D1 assessments with an M0090 (Date the Assessment Is Completed) equal to January 1, 2020 or later, HHAs may enter an equal sign (=) for the items. This is a new valid response for select M items for the time points listed below (the items themselves remain unchanged).
Start of Care/Resumption of Care (SOC/ROC) M1910 Fall Risk Assessment
Transfer (TRN) and Discharge (DC) M2401(A) Intervention Synopsis: Diabetic Foot Care M1051 Pneumococcal Vaccine M1056 Reason Pneumococcal Vaccine Not Received
ACCURATE OASIS-D1
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Optional Items on Follow-Up & Other Follow-Up M1021: Primary Diagnosis M1023: Other Diagnosis M1030: Therapies M1200: Vision M1242: Frequency of Pain Interfering M1311: Current Number of Unhealed Pressure Ulcers at Each Stage M1322: Current Number of Stage 1 Pressure Ulcers M1324: Stage of Most Problematic Unhealed Pressure Ulcer that is
Stageable M1330: Does the Patient Have a Stasis Ulcer? M1332: Current Number of Stasis Ulcer(s) That Are Observable
ACCURATE OASIS-D1
Optional Items on Follow-Up & Other Follow-Up M1334: Status of Most Problematic Stasis Ulcer that is Observable M1340: Does the Patient Have a Surgical Wound M1342: Status of Most Problematic Surgical Wound That Is
Observable M1400: Short of Breath M1610: Urinary Incontinence or Urinary Catheter Presence M1620: Bowel Incontinence Frequency M1630: Ostomy for Bowel Elimination M2030: Management of Injectable Medications M2200: Therapy Need
ACCURATE OASIS-D1
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ACCURATE OASIS-D1 There are very specific updated instructions for completing and
transmitting Follow-Up/Recertification OASIS for patients that will be recertified during the last few days of 2019 and the recertification episode will begin January 1, 2020 and later under the new PDGM.
When the recertification is completed within the last 5 days of 2019, CMS will temporarily waive the requirement that HHAs enter the actual OASIS “Date the Assessment Is Completed” date in M0090. Instead, agencies are required to enter the M0090 date as 1/1/2020. The agency must wait to transmit the OASIS until 1/1/2020, or there will be a fatal error.
ACCURATE OASIS-D1
Transition Recertification Example: Start of Care date: November 3, 2019 Recertification assessment (using OASIS-D1 Follow-Up (RF4)) is
completed on December 29, 2019 (the episode is to begin January 2, 2020)
Report artificial M0090 date of 1/1/2020 Submit the OASIS to the ASAP database 1/1/2020 or later
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IQIES – REGISTER BY DECEMBER 23 Why register in the upgraded internet Quality Improvement
and Evaluation System (iQIES) by December 23? Beginning January 1, 2020, you must use iQIES to submit patient
assessments and view associated reports. You must register and verify your identity in the HCQIS Access Roles and Profile (HARP) system before logging-in to iQIES.
The iQIES system will be down periodically in preparation for the January 1, 2020, iQIES release.
To access iQIES, you must identify the Provider Security Official (PSO). Register two PSOs if possible; they must approve or reject user access requests for your organization, including vendors. Registered security officials have access to “My Profile” and “Help” in iQIES. Note: The rollout of iQIES will not change how you submit data.
The 21-month transition period will end on December 31; use Medicare Beneficiary identifiers (MBIs) now.
Agencies are currently submitting 86% of claims with MBIs.
Get MBIs from your patients and through the MAC portals now and after the transition period. You can also find the MBI on the remittance advice.
Protect your patients from identity theft - use MBIs.
MEDICARE BENEFICIARY IDENTIFIER (MBI)
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MEDICARE BENEFICIARY IDENTIFIER (MBI) Span-date claims – You can use HICNs or MBIs for 11X-Inpatient Hospital,
32XHome Health (home health claims and Request for Anticipated Payments [RAPs]) and 41X-Religious Non-Medical Health Care Institution claims if the “From Date” is before the end of the transition period (December 31, 2019). If a patient starts getting services in an inpatient hospital, home health, or religious non-medical health care institution before December 31, 2019, but stops getting those services after December 31, 2019, you may submit a claim using either the HICN or the MBI, even if you submit it after December 31, 2019. Since you submit home health claims for a 60-day payment episode, you can send in the episode’s RAP with either the HICN or the MBI, but after the transition period ends on December 31, 2019, you have to use the MBI when you send in the final claim that goes with it.
HOME HEALTH FINAL RULE 2020
PDGM – FINAL RATES INCLUDING DECREASING BEHAVIORAL ADJUSTMENT
PPS 2020 Rates – including LUPA Rates, Rural Add-OnHHVBPTherapy Assistants providing Maintenance TherapyReduction of POC requirements as condition of
payment Home Infusion Therapy
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FINAL RATES PPS CLAIMS 2020
The PPS claims with a start date of 12/31/19 and prior will still be paid under the PPS model and the following is the FINAL base rate: $3,220.79
The structure for calculating the HIPPS code under PPS has not changed
Wage Index for all counties updatedLUPA Rates updated – see following screen – these will
be the LUPA rates under PDGM, as well.
LUPA RATES FINAL 2020
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NON-ROUTINE SUPPLIES RATES PPS 2020
RURAL ADD-ON 2020 - 2022 (PPS & PDGM)
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OUTLIER CALCULATIONS FOR PPS & PDGM
Under 60-day PPS episodes there will be no change to the Outlier Fixed Dollar Loss (FDL) ratio of 0.51
Under 30-day PDGM payment periods there will be a change in the FDL to 0.56 This increase in the FDL means that the agency will incur more
calculated cost prior to an outlier kicking in.
PATIENT-DRIVEN GROUPINGS MODEL (PDGM)
Behavioral Adjustments (4.36% FINAL RULE 8.01% - as proposed July 2019) -Diagnosis coding, Comorbidities, LUPA avoidance $1,864.03 FINAL RULE - - $1791.73 proposed 2019 - - proposed 2018-$1753.68 - - proposed HHGM-$1607 LUPA: 2‐6 visits @ 10th percentile value of total visits in payment group Outlier based on 30 day unit of payment – Fixed Dollar Loss Ratio proposed 0.63 FINAL RULE 0.56 PEP adjustments will be based on 30 day periods Therapy Thresholds are NO MORE
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PATIENT DRIVEN GROUPINGS MODEL (PDGM)
432 payment groups – increased from 216 groups originally proposed
Episode timing: “early” or “late” Admission source: Community or Institutional Clinical grouping: 12 sub-groups (primary diagnosis) Functional level: 3 groups – Low, Medium or High Comorbidity adjustment: None, Low or High (secondary
diagnoses)
PATIENT DRIVEN GROUPINGS MODEL (PDGM)
Admission Source & Timing (Claims) - (Community Early, Community Late, Institutional Early or Institutional Late)
Only the first 30-day period will be considered Early and all others late. Similar to the current PPS model, the payment period could only be considered Early if greater than 60 days has passed since the end of a previous period of care.
IMPORTANT - - However, if a patient experiences a significant change in condition before the start of a subsequent, contiguous 30-day period, for example due to a fall; a follow-up assessment would be submitted at the start of a second 30-day period to reflect any changes in the patient’s condition, including functional abilities, and the second 30-day claim would be grouped into its appropriate case-mix group accordingly
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PATIENT DRIVEN GROUPINGS MODEL (PDGM)
Admission Source & Timing (Claims) - (Community Early, Community Late, Institutional Early or Institutional Late) Admission Source will be Community or Institutional – depending on
the healthcare setting utilized in the 14 days prior to home health (inpatient acute care hospitalization, skilled nursing facilities, inpatient rehabilitation facility, psychiatric or long term care hospital)
IMPORTANT: A post-acute stay (SNF, Rehab, LTCH, or Psych) in the 14 days prior to a late home health 30-day period would not be classified as an institutional admission unless the patient had been discharged from home health prior to the post-acute stay
PATIENT DRIVEN GROUPINGS MODEL (PDGM)
Medication Management, Teaching and Assessment (MMTA) • MMTA – Surgical Aftercare • MMTA – Cardiac/Circulatory • MMTA – Endocrine • MMTA – GI/GU • MMTA – Infectious & Blood-forming Diseases/Neoplasms• MMTA – Respiratory • MMTA – Other
• Neuro Rehab • Wounds • Complex Nursing Interventions • Musculoskeletal (MS) Rehab • Behavioral Health
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PATIENT DRIVEN GROUPINGS MODEL (PDGM)
Functional Level (OASIS Items) – (Low, Medium, High)
Anticipates roughly 33% of periods of care will fall into each of the categories.
M1800-M1860 (not M1845) and M1033 are OASIS-D1 Items proposed for use in determining Functional Level under PDGM.
OASIS Points Table – **October 2019
VariableResponse Category Responses Points
M1800: Grooming 1 2, 3 5
M1810: Current Ability to Dress Upper Body 1 2, 3 6
M1820: Current Ability to Dress Lower Body 1 2 6 5
2 3 12
M1830: Bathing 1 2 3
2 3, 4 12 13
3 5, 6 20
M1840: Toilet Transferring 1 2, 3, 4 5
M1850: Transferring 1 1 3
2 2, 3, 4, 5 6 7
M1860: Ambulation/Locomotion 1 2 9
2 3 11
3 4, 5, 6 23
M1033: Risk of Hospitalization
4 or more items
checked From 1‐7 11
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MMTA ‐ Surgical Aftercare Low 0‐37
Medium 38‐50
High 51+
MMTA ‐ Cardiac and Circulatory Low 0‐36
Medium 37‐52
High 53+
MMTA ‐ Endocrine Low 0‐34
Medium 35‐52
High 53+
MMTA ‐ Gastrointestinal tract and Genitourinary system Low 0‐41
Medium 42‐54
High 55+
MMTA ‐ Infectious Disease, Neoplasms, and Blood‐Forming Diseases Low 0‐36
Medium 37‐52
High 53+
MMTA ‐ Respiratory Low 0‐37
Medium 38‐52
High 53+
MMTA ‐ Other Low 0‐36Medium 37‐52High 53+
Behavioral Health Low 0‐36
Medium 37‐52
High 53+
Complex Nursing Interventions Low 0‐38
Medium 39‐58
High 59+
Musculoskeletal Rehabilitation Low 0‐38
Medium 39‐52
High 53+
Neuro Rehabilitation Low 0‐45
Medium 46‐60
High 61+
Wound Low 0‐41
Medium 42‐59
High 60+
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No Comorbidity AdjustmentLow Comorbidity Adjustment One or more of 13 subgroups met Consists of one dx from subgroup
High Comorbidity Adjustment One or more of 31 subgroup interactions met Consist of one dx from two different subgroups
Comorbidity Adjustment
REQUEST FOR ANTICIPATED PAYMENT (RAP)
Required for each 30-day payment periodProposed 07/2019 to be Paid at 20% INSTEAD of
No payment for HHAs Medicare certified in 2019 or thereafter 2019 certified HHAs required to submit “no-pay” RAPs
RAPs to be phased out - RAPs with NO PAY for all in 2021 RAPs PROPOSED July 2019 to be replaced by a Notice of
Admission (NOA) effective January 1, 2022
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FINAL CLAIMS – BILLING REQUIREMENTS All payment periods
OASIS assessment(s) transmitted to & accepted at ASAPSOC, recertification, ROC or other follow-up, if
applicable Compliant F2F encounter documentation obtained All physician orders signed & dated
POC & all other interim orders applicable to payment period
All billable visit & NRS documentation completed Compliant therapy reassessment documentation
completed
FINAL CLAIMS – BILLING REQUIREMENTSSome data required on a PPS Final claims will be tweaked for PDGM:
18-digit Treatment Authorization Code/OASIS Matching Key will NO Longer exist under PDGM
Occurrence Code 50 will be entered on the Final claims with the Occurrence Date equal to the date the assessment is completed from M0090 of the OASIS that your system used to create the HIPPS
Occurrence Codes 61 & 62 will be utilized on 1st (initial) 30-day payment period Finals to signify that the patient is an Institutional patient status – 61 can by used on 2nd 30-day payment periods: Occurrence Code 61 – with the date of the ACUTE HOSPITAL
discharge date that was within 14 days prior to the HHA start date Occurrence Code 62 – with the date of the SNF, IRF, LTCH or IPF
discharge date that was within 14 days prior to the HHA start date
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PAYMENT ADJUSTMENTSPartial Episode Payment Adjustment (PEP)
Applies to three intervening events occurring during a 30-day payment period: Beneficiary elected transfer to another agency - Discharge from your agency & subsequent readmission to your agency or another HH -Change from traditional Medicare to Medicare Advantage plan
Claim payment prorated based on first & last billable visit dates during 30-day payment period
Outliers Applies to high cost 30-day payment periods based on time spent in
home during visits – units reported on the claim Method of calculation unchanged from PPS, BUT FDL will now be 0.56 -
applied to 30-day period
LUPA THRESHOLDSVariable thresholds based on Case Mix Grouping – Updated in Proposed Rule July 2019
Different level for each of the 432 Case Mix Groupings – ranges between 2 - 6 visits.
Based on 30-day payment periods – NOT 60-day episodes Utilize 10th percentile value of visits for each threshold LUPA reimbursement is per visit (as prior PPS)
LUPA add-on Applies only to SOC 30-day payment periods with total visits at or
below LUPA visit threshold
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FINALIZED CHANGE TO MAINTENANCE THERAPY
Therapy assistants may perform maintenance therapyProposed regulatory language only addresses PT
assistants POC
POC ITEMS NEEDED FOR COVERAGE
Revising requirements for payment§409.43 to read “… the home health plan of care must include
those items listed in §484.60(a)that establish the need for service.”POC must include items and services needed for coverageMissing items required at §484.60(a) not needed for coverage are
best handled by surveys and not claims denials – therefore reviews under Targeted Probe & Educate should NOT be denied for missing items on the POC
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HHCAHPS FINAL RULE 2020
FINALIZED to remove question #10 effective July 2020“In the last 2 months of care, did you and a home
health provider from this agency talk about pain?”
HOME INFUSION THERAPY BENEFIT
New benefit under Part B required by the 21st Century Cures Act New supplier designation – “Home Infusion Therapy Supplier” Coverage for associated professional services for infusion on a
pump in the home, which include Home Health & Hospice Transition payment period 2019-2020 - Permanent 2021 This benefit will ONLY be for Infusion in the HOME
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HOME INFUSION THERAPY BENEFIT
Coordination with Home Health Professional service associated with this new home infusion therapy
benefit must be provided by the home infusion therapy supplier under Part B, not home health – effective 2021
If a beneficiary is receiving HH by agency that is also a qualified home infusion supplier, CMS will permit the HH to bill for the infusion therapy services separately under new Part B home infusion benefit – effective 2021
During transitional period Home Health continues to provide infusion therapy for patients under a HH POC
HOME INFUSION THERAPY BENEFIT
Policies in 2021 Patient notification by the physician on site of care options (physician
office, outpatient, home)
POC frequency of physician review Specificity of orders related to infusion therapy
Payment Rates based on 3 drug categories Charts with the drugs included under each category Rates for each category
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THANK YOU FOR PARTICIPATING!Melinda A. Gaboury, COS-C
Chief Executive OfficerHealthcare Provider Solutions, [email protected]
targetedprobeandeducate.comhealthcareprovidersolutions.com/pdgm
615-399-7499
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