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What does this mean for your agency?

The 2015 PPS Rule brings many changes including the elimination of case-mix points for nearly 200 codes from pulmonary, psych 1 and 2, as well as blindness/low vision diagnoses categories.

OASIS items such as M1200 (Vision) and M2030 (Injectable drug use) will lose case-mix value. In general, there is a reduction of case mix diagnoses for clinical items but high therapy (14+ visits) episodes garner more points.  Industry experts believe we will see more therapy in cases as the reward for higher therapy episodes is there. Other experts believe the trend of declining home health aide utilization will continue as agencies strive to better manage certain cases such as those with high ADL assistance. In certain of these cases, an OT consult, plan, and OT intervention could decrease dependence on an aide and focus more on patient and/or patient caregiver optimal level of functioning and caregiving.

Recalibration of case mix adjuster

The recalibration of the home health case-mix adjuster can have significant impact on individual agencies. From 2000-2014, the 124 variables remained relatively the same, but in 2015 there has been significant change as CMS overhauls the four equation model which has been used to determine clinical and functional points for episodes. The new 124 variable model saw 63 prior variables dropped with 21 new variables added. Collectively, this new model impacts all 153 case-mix categories. (Dombi, 11/19/2014 NAHC Seminar).

CMS states the changes are to be budget neutral, however, some home health experts state home health agencies that focus on skilled nursing services with less therapy are likely to experience reimbursement decreases. Many experts have states their surprise at the reward for high therapy episodes. CMS contends the changes occurred because of utilization patterns in 2013 final claims data. This means that one thing is clear, therapists are documenting time spent with the patient better than nurses. They are accustomed to justifying billable time. Nurses are going to need to be more exact as to the tasks and education completed with the patients and families and have the documentation that supports the depth of time spent to achieve the skilled visit.

Coding Guidelines have not changed

The Coding Guidelines have not changed, so coding for COPD, depression or Alzheimers will still occur as appropriate. Those codes just will not garner the case mix points once attached. CMS continues to seek the appropriate portrait be painted of the patient’s conditions and needs.

Additional areas of focus

For instance CMS is honing in on insulin injections being given by home health agencies. CMS expects to see supportive diagnoses that justify why the patient requires agency personnel to administer prescribed insulin. They have identified 164 diagnoses, certain of which they expect to see on final claims when a patient is receiving agency administered insulin injections. Those diagnoses categories include:

  • Cognitive/behavioral conditions
  • Arthritis
  • Vision condition
  • Amputation
  • Effects of Stroke and other disorders of the Central Nervous System

CMS will be monitoring claims of insulin injection administered by the home health agency. More and more, agencies are seeing the need for coding experts. Missing supportive codes could mean ADRs.

Diagnoses with case mix attached

Diagnoses groups that have case mix still attached include:

  • Selected benign neoplasms
  • Cancer
  • Stroke
  • GI disorders with ostomy
  • Heart disease or HTN, not both
  • Ortho conditions
  • Skin ulcers
  • Tracheostomy
  • Urostomy
  • Certain Brain disorders
  • Paralysis

Monitoring Documentation by independent experts

It appears the home health industry will continue to lose further case mix diagnoses if documentation is not substantive to quantify time spent with the patient and family delivering skilled services. Agencies need claims submitted with correct primary diagnosis, supporting diagnoses, and comorbidities.  Who is monitoring the documentation at your agency?  Acquiring revenue is easy. Keeping your revenue through an audit is more difficult. Be certain there is congruence between the codes chosen to describe the patient and the documentation written to describe the patient condition, interventions, and plans. Having third party expert coding specialists can make the difference. To learn more, contact Select Data.

ICD-10 is 10 months away

Remember, ICD-10 is coming. If your agency has difficulty with documentation under ICD-9 CM, ICD-10 CM is far more detailed. Intervene now and prepare for ICD-10. Call Select Data now for more information on how you can be better prepared for ICD-10.

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