Archive for the ‘CY2012’ Category

Bulletin: ICD-10 is Still Coming. The question is WHEN.

Friday, February 17th, 2012

Yes, it is true that on February 14, 2012, CMS Acting Head, Marilyn Traverner, told the press that CMS will “reexamine the timeframe” of implementation of ICD-10 CM. She stated the timeframe will be examined through the rule making process, but no word as to when that process will begin.

The AMA lobbied hard for the delay of the ICD- 10 morbidity classification. On the other hand HIMSS (Health Information Management Systems Society) stated that ICD- 10 is “the very basic foundation of healthcare change”.

As we all are aware, ICD-10 will replace a 30 year old system that has not kept up with modern terminology and clinical practices. ICD- 10 offers detailed information on the patient’s condition through specific diagnoses. It is expected to allow upgrading of current data analysis of both diagnoses and procedures with improved care management for patients/clients as an outcome. It has increased capability allowing for far greater detail of the patient’s illness.

Because of increased specificity, the expectation is that interventions for chronic diseases will occur sooner. ICD-10 will allow tracking of disease severity and progress measurement as well as design educational programs for disease clusters identified. It is also expected to identify disease groupings that “may merit special attention” as well as the designing of new care management programs. It allows the US to work more closely with other countries.

The new system gives a much greater granularity to classifying disease and injury.  For instance, ICD- 9 still includes categories for injuries rarely seen, such as accidents in chicken coops and opera houses. It also has only 5 digit codes with no room for expansion.

HIMSS believes that there is “achievable value in the adoption of ICD-10″ by the original deadline, the group said in a 2/10/2012 press release.”The use of this more robust and upgraded data classification system, with the capacity to include current medical knowledge and 21st century patient procedures, will improve health care.”

Many healthcare experts believe that, at best, the ICD- 10 system is delayed for a short time only. The system has real merit, is needed for the specificity and accuracy required, and the US, in order to work with most other industrialized nations, must recognize that other countries are already using ICD 10.

As America considers when to implement ICD-10, ICD-11 is already in the works. The WHO, (World Health Organization) which already hosts an alpha-draft on its website, hopes to have a public beta this spring and a working version up in 2015.

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Posted in CMS, CY2012, ICD-10-CM Coding, ICD9-CM Coding, Medicare, MICs, OASIS-C, RACs, Z-PICs | No Comments »

CODING 2012: ICD-10-CM is Upon Us Next Year

Friday, February 17th, 2012

Agency leaders know that now more than ever, coding is driving payment and is a focus of audit by RACs, MACs, and Z-PICs. It is imperative that the primary diagnosis, primary secondary diagnosis, and sequencing of all codes clearly delineate the picture of the patient and his/her condition. The codes are the Table of Contents in the home health chapter of the book known as the patient clinical record.

Agency leaders want appropriate payment and compliance. Equally important, they want to retain that payment received. At VNAA’s 30th Annual Meeting In early May, 2012 preparing for ICD-10 will be discussed in depth, but what are some of the general concepts and constructs that differ from ICD-9 CM? To prepare for this grand change, what should you do? Commit to learning about ICD-10 CM. It impacts more than just the coding department. Everyone in your agency will be impacted.

CMS is preparing. While Home Health Agencies were focusing on new CY 2011 regulations and plenty of changes last year, agency leaders were aware that there was a change to Version 5010 for handling electronic claims. CMS will still accept Version 4010 claims for a short period. This billing change was necessary in preparation for ICD-10 CM scheduled for October 1, 2013.

The ICD-9 CM Coordination and Maintenance Committee

“Recognizing the ICD-9-CM as a dynamic statistical tool that must be flexible to meet expanding classification needs, the ICD-9-CM Coordination and Maintenance Committee was created as a forum for proposals to update ICD-9-CM.  A representative from the National Center for Health Statistics (NCHS) and one from the Centers for Medicare and Medicaid Services (CMS) co-chair the ICD-9-CM Coordination and Maintenance Committee meetings.  Responsibility for maintenance of the ICD-9-CM is divided between the two agencies, with classification of diagnoses (volumes 1 and 2) by NCHS and of procedures (volume 3) by CMS”. (http://www.cdc.gov/nchs/icd/icd9cm_maintenance.htm).

The ICD-9-CM Coordination and Maintenance Committee’s role is advisory. The Director of NCHS and the Administrator of CMS make all final decisions. Final decisions are made after the December meeting and become effective October 1 of the following year. Official code revision packages, which are referred to as addenda, are available from this site.

The transition to ICD-10 is a major change for the industry. To better effect that transition as well as the Version 5010 to handle electronic claims, the ICD-9-CM Coordination and Maintenance Committee proposed and accepted a partial freeze. This freeze identifies:

  • The last regular annual updates to ICD-9-CM and ICD-10-CM were made October 1, 2011
  • Limited updates to ICD-10 CM for October 1, 2013 (ICD-10-CM is expected to be fully in use in Home Health by 2013)
  • Full regular updates to ICD-10 CM to be reinstituted October 1, 2014

What is ICD-10 CM?

  • ICD-10 CM is the US “Clinical Manifestations” of the World Health Organization (WHO) ICD-10 Code Set.
  • ICD-10 PCS is a US creation for procedure codes only that will essentially be used in the acute care setting.
  • ICD-10 CM brings the US in alignment with the worldwide coding system.
  • ICD-10 CM offers greater coding specificity and accuracy.
  • IVD-10 CM offers increased capability to measure healthcare quality, safety, and efficiency.

Transaction version changes (X12 version 5010) must be in place to handle the new codes and its seven digits, thus the changes for billing this year.

CMS states, ICD-10 is markedly different from ICD-9 and they expect adjustment reaction to cause slowing in payment. Many coding experts believe that, with proper planning, that need not be the case.

“ICD-10 requires changes to almost all clinical and administrative systems. It requires changes to business processes.”  Per CMS

Why Must We Change to ICD-10?

  • ICD-9-CM is over 30 years old.
  • ICD-9 CM has no more room to add new codes or keep pace with current classification of Medical conditions or technological advances.
  • ICD-9 CM is not always precise or unambiguous.

US mortality data is being reported in ICD-10 thus making comparison of mortality and morbidity difficult.

ICD- 10 CM offers:

  • Lower Costs through increased efficiencies
  • Synergistic effects with the Electronic Health Record (EHR)
  • Clearer recognition of medical advances
  • Clearer recognition of technological advances

What are some of the Differences between ICD-9-CM and ICD-10-CM?

ICD-9-CM

17 chapters and V and E code chapters

13,000 disease codes plus V and E codes

3,000 procedure codes in Volume 3

3-5 digits in disease codes

Essentially numeric system

Codes usually do not indicate timing                                                                                            encounters

No differentiation between left/right

ICD-10-CM

21 chapters- V and E codes in disease chapters

68,000 disease codes, including V and E codes

87,000 procedures codes in ICD-10-PCS

3-7 digits in disease codes

Alphanumeric system

Codes specify initial and subsequent encounters

Differentiates between the right and left

Solid understanding of  anatomy, physiology,  and diagnostics will be a must.

In May, come to the session:  Start Preparing NOW for ICD-10 CM Coding and receive a plan for your coding teams’ educational preparation needs with examples of how to review anatomy, physiology, and diagnostic essentials.  It may seem like ICD-10 is far away but, an additional 55,000 diagnostic codes, a change in chapters, and required increased coding specificity to the 7th digit means increased risk for payment and more importantly, increased risk for payment retention. If your payment retention becomes in question, can the MACs, RACs, or Z-PICs be far behind? Could you survive what is coming with the coding preparation you have right now?

This article was written by Susan J. Carmichael MS, RN, CHCQM, COS-C, FAIHCQ, Susan is the Executive Vice President, Chief Clinical Officer and Chief Compliance Officer for Select Data, a national firm providing Revenue Cycle Management services, software, and process solutions to the home health industry for over 20 years. Susan has held C Level positions for nonprofit, and publicly traded home health firms. She has taken agencies to both the American and NASDAQ Stock Exchanges, has grown multi-state Medicare-Medicaid/Private Duty/Staffing agencies by both acquisition and native growth, and is credited with growing one firm from billing $114.00 (first week) to $515,000 per week in less than five years. Susan’s latest publication was The Remington Report, July/August, 2010Recovery Audit Contractors (RACs): Seven Major Changes to the Permanent Program and in the September/October issue: The RAC Attack: How to Prepare and Manage the Audits. Susan is a frequent requested speaker at state association conferences on industry topics, including OASIS, Coding, RACs/MACs/MICS/Z-PIC audits, and Corporate Compliance program essentials.

VNAA is proud to have Select Data as an Associate Member and Member Update Sponsor. Please support our sponsors like Select Data that support VNAA by visiting their Website and checking out their services.

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Posted in CMS, CY2012, Home Health, ICD-10-CM Coding, ICD9-CM Coding, MACs, Medicare, MICs, OASIS-C, RACs, Z-PICs | No Comments »

The Performance Improvement Plan; Silent but Powerful

Thursday, January 19th, 2012

Among RACs, MACs, MICs, and Z-PIC concerns, along with new survey protocols, new CY 2012 regulations, the advent of 5010, Accountable Care Organizations, and looming ICD-10 CM, what tools can a leader utilize to help mitigate risk? One such tool is the agency Performance Improvement Plan.

Some agencies treat these plans as necessary evils while others embrace the strength of the process and its ability to reduce risk. Recently, we have been asked about initiating a workable, useable, beneficial program.

The Purpose

The purpose of a Performance Improvement Program, Plan, or Process (PIP) is to outline a process that needs improvement. The team that will review the improvement process needs to baseline the present processes seeking efficiencies or other outcomes. This Performance Improvement Plan should support the organization Mission and its Corporate Plan.

Quality Concepts

·            The PIP is established to benefit the organization. It should address an issue or issues that require improvement.

·            The entire organizational team chosen for this Program should be actively included in all phases.

·            Focus on patient or operational outcomes, but try not to take on too many projects at once.

Suggested Patient Care Functions

·            Rights and Responsibilities

·            Ethics and Compliance

·            Assessment and OASIS

·            Adequate Documentation of Care

·            Patient Education and Re-Teaching

·            Continuum and Care Transitions

Agency/Organizational Operations

·            Leadership

·            Ethics and Corporate Compliance

·            HIPAA Privacy and Security

·            Management of Resources

·            Appropriate and Current Policies and Procedures

·            Infection Control

·            Supportive Environment Conducive to Optimum Employee Performance

·            Safety

·            Fiscal Soundness

Responsibility

The Board of Directors approves the Agency Administrator position and the Performance Improvement Program supports with adequate resources and financial support. The Agency Administrator oversees the program or appoints a delegate and assures the Program is continuous, is providing meaningful process monitoring and improvement. Annually, at minimum, results are reported to the BOD.

The Process and the Design

Processes should approach an issue that requires improvement. Processes are designed to be in alignment with the agency mission and strategic plan. They should also be based on evidenced based processes or best practices. They may be benchmarked against other organizations.

Measurement

There needs to be a sound way to collect data. The data will be collected, measured, and analyzed. The goal is to decide the statistical control methods, agree upon how the data will be collected, and determine how it will be measured. Is the agency seeking to evaluate a present process? Design a new process? Assess Performance? Identify areas of Improvement?

Over what period of time will you collect data? Will you evaluate your methods of collection and tools of measurement? Will you evaluate unusual occurrences? Will you keep drilling down until you locate the root cause of the issue?

Assess

The agency should be assessing for improved efficient processes. Will you analyze and discuss new processes so the best process is chosen. Who will be involved? How will they be involved? Will you reevaluate the new processes? When?

Improvement

Buy- in comes with improvement. Be certain that the new processes are truly an improvement. For each issue resolved or impacted, be certain there are clear recommended actions with a responsible party named who will monitor the new processes. Have a timeframe delineated for evaluation as well as evaluation of the “improvement.” Be certain everyone knows the expected outcome. Survey results and identify satisfaction levels.

Buy- In

Buy- in can drive motivation and success. It is important that employees see results for the extra work of the PIP. This process can be applied after Organization Risk Assessments. It teaches problem resolution and hones skill sets. It encourages team building and drives results in an organized fashion. Organizational learning is essential for success. This is one simple way of achieving positive results while reinforcing respect and value for each employee.

Recently, I was speaking with an agency leader, whose firm is known for its Performance Improvement Projects. She has two teams. The key is fun as they attack real problems. Each team identifies projects that impact improved care, outcomes, impact employee morale, or directly impact costs. They present two projects each to the BOD or the Professional Advisory Committee. This allows many to be involved,

Each team defends their chosen project as to benefits derived. They defend the value of the project. Each year the BOD presents a cash bonus and dinner to the team with the best project over the past 12 months. The Leader stated employees via to be on the committees and the PIP are becoming more creative. They are “attacking real problems and finding real solutions we all can live with.” Employees see they are impacting positively on their agency; its care and reputation. They also see the value of group dynamics, peer pressure, and improved performance.

For 2012, the employees have proposed a third team. Leadership is thrilled at that proposal and the fact that she frequently hears, “That should be referred to the PIP, because we can do better.”

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Posted in (PIP), CMS Guidelines, Compliance, CY2012, Home Health, ICD-10-CM Coding, MACs, Medicare, MICs, OASIS-C, Performance Improvement Program, RACs, Z-PICs | No Comments »

Ethics and Accountability in an Electronic Age: 2012

Wednesday, December 28th, 2011

You are a leader or have interests in home healthcare and hospice, so you are aware of the challenges and opportunities presented in this electronic age.

Are you conducting your HIPAA Risk Analysis?

Do you have your Disaster Preparedness and Recovery Policies and Procedures current?

Do you have a policy regarding use of social media in the workplace?

Are you allowing nurses to take pictures of wounds with their personal cell phones?

Are you employing etechnology ethics ?

Technology and Change:

Today, we all use a GPS, an iPhone, a Droid or some brand of cell phone, and touched our iPad or other tablet,  powered up a laptop or computer to send email, or completed status updates to Facebook,  Linkedin, or Twitter or accessed the Internet for  patient information, financial or clinical reports and benchmarks, or budgets. Technology has not necessarily made life easier. It certainly has increased its constraints on time.

Technology has impacted how we do banking, make purchases, conduct transactions, complete travel reservations, attend conferences, provide healthcare schedules, teach patients and personnel, automate revenue cycle management, and generate personnel schedules and  agency reports.

The negative effects include:

5/19/11 57 hard drives from the servers at the Blue Cross Blue Shield Tennessee Call Center were stolen with 1 million individuals impacted.

9/29/11  4.9 million Tricare beneficiaries affected after data stolen.

10/11 McAfee demonstrated how they could hack into a Medtronic Insulin Pump and could have lethally increased the dose.

2010 File boxes of patient records found in two major cities.

The world is changing. The workforce is changing. Remote workers need special policies re PHI and protection of patient data. Be certain they attend sessions regarding HIPAA HITECH, privacy, and security. You may have a policy that addresses ‘view only’ access to data with no printing of data.

HIPAA HITECH

The American Recovery and Reinvestment Act of 2009 (ARRA) was signed into law on February 17, 2009.  Title XIII of ARRA is the Health Information Technology for Economic and Clinical Health Act (HITECH Act). HITECH legislation is meant to affect health care delivery

  • One way to affect change is to provide financial stimulation to create and have physicians and hospitals adopt electronic health records (EHR)

The Federal operating plan can be found at http://www.hhs.gov/recovery/reports/plans/onc_hit.pdf

This act includes $20 billion in funding for health information technology projects.

These projects include reimbursement incentives for health care providers to acquire electronic health record technology.  Hospitals are being encouraged to move toward becoming paperless.

HITECH has TEETH

The HITECH Act has given the HIPAA Privacy and Security Rules real teeth by strengthening business associates agreements.  One of the major goals of the HIPAA  Privacy Act was and is  “to assure that individuals’ health information is properly protected  while allowing the flow of health information  needed to provide and promote high quality health care and to protect the public’s health and well being.” HIPAA ensures that personal health information  given to covered entities is protected, even information shared with home health agencies, physicians, hospitals, third party billing providers, coding specialists, and others who provide or pay for healthcare services. But Business Associates were not held to the same standards as covered entities. HIPAA HITECH moved to correct this weakness.

BUSINESS ASSOCIATES

  • The BAA states that the Business Associate is obligated to:
    Use/disclose PHI only as permitted or required by the agreement and by law.
    Use appropriate safeguards to prevent use or disclosure of PHI other than as permitted by the BAA.
  • Report to the healthcare entity any use or disclosure of PHI not permitted. Require all subcontractors and agents that create, receive, use, disclose, or have access to PHI to agree, in writing tobe held to the same restrictions and conditions on use or disclosure of PHI.

HIPAA HITECH imposed breach notifications on both covered entities and business associates and increased individual rights with respect to PHI maintained in EHRs. In addition, there is increased enforcement of, and penalties for HIPAA violations..

The Department of Health and Human Services (HHS) has published a notice of proposed rulemaking that would modify the HIPAA Privacy, Security, and Enforcement Rules. The Proposed Rule implements the requirements of the HITECH Act as well as expands upon the statutory provisions of the HITECH Act.  On March 15, 2010 HHS stated that other than the security breach notification rule and new penalty levels, the new regulation would be enforced. The compliance date for all provisions of the Proposed Rule is 180 days after publication of the Final Rule. HHS accepted comments on the Proposed Rule through September 13, 2010. As of January, 2012, the final rule has not yet arrived, but is expected soon.

Prior to the HITECH Act, a Business Associate (BA) was not directly subject to HIPAA privacy and security requirements.  The BA obligations were to the CE under the terms of the agreement. The BA was subject to contractual remedies only for any breach of the business associate agreement (BAA).

  • Prior to ARRA, HITECH Business Associates were not required to meet the obligations for Administrative, Physical, and Technical safeguards, and Procedure and Documentation Requirements.
  • NOW the BAA must clearly require the BA to comply with HIPAA regulations just as the CE.

Penalties for the BA are the same as the CE. That is a huge responsibility for the BA and the CE.

The HITECH Act and the Proposed Rule require business associates to comply with the requirements of the HIPAA Security Rule and implement policies and procedures in the same manner as the CE. Also, subcontractors to business associates must develop Security Rule compliance programs. Rules to be followed include:

Security and Incident response policies

  • Breach Log
  • Every employee must understand they have personal responsibility for intentional breaches
  • Email with PHI is to be encrypted

Breach:

A breach is an unauthorized acquisition, access, use, or disclosure of protected health information relating to failure to comply with organizational security or privacy policies, or violation of federal or state privacy and security regulations. Accessing information by an employee of a covered entity, in good faith, is not considered a breach.

However, HITECH strengthens the specifics of privacy and security, significantly increasing penalties, establishing a heightened enforcement scheme giving state attorneys general enforcement authority. Individuals may now be held accountable for wrongful disclosure (HITECH Act section 13409).

Under the new law, when a breach is learned, a covered entity (CE) should notify each individual whose unsecured PHI has been, or believed to have been, accessed or disclosed.  Business associates must notify the CE of the breach.  Note the understanding that the breach has been evaluated to have caused harm to the individual.  CE and BAs must notify individuals about a breach as soon as possible but, no later than 60 days following discovery of the breach.

If a breach involves 500 or more individuals, the department of Health and Human services should be immediately notified. They will post the covered entity on their website. DHHS began posting names on March 1, 2010. Breaches of below 500 must be recorded on a log and annually sent to DHHS.

UCLA Medical Center recently was fined $865,000 and required to submit(and have approved) a corrective action plan after allowing workers to access records who should have had more  limited access and a higher level authorization. This is an organization with a sophisticated compliance plan and still had this breach.

The EHR

The Privacy Rule gives individuals the right to obtain copies of their paper PHI from a CE. The HITECH Act expanded those access rights to PHI maintained in an EHR.

ARRA prepares for the government goal of establishing electronic health records for all Americans by 2014

  • to accomplish this goal, privacy rules have been strengthened and the requirements for breach notification and responsibilities of business associates have been greatly increased.

CEs must prepare processes in response to the requirements and have updates to the BAA.

At Select Data,

  • We believe in Corporate Compliance
  • We have a strong HIPAA Awareness and Corporate Compliance Plan which assertively strives to protect PHI.
  • We notify the Corporate Compliance Officer of suspected or actual incidents of PHI disclosure

We want to comply with the regulations and we want to protect health information because, not only is it the law, but, it is the right thing to do.

57 million US consumers have accessed their medical information. Another 40 million want to do so states Cyber Citizen Health US, 2011 survey.

DISASTER PREPAREDNESS

The Security Plan: Each CE must plan and document how they will operate during a disaster and how ePHI will be secured. HIPAA 2005 required a Data Backup Plan. That plan requires the backup plan for accessing protected data in case the original data has been destroyed.

The Plan must show regular duplication of patient files that are stored in a secure location. The Plan also required an inventory of software and hardware used so key systems can be restored quickly, if a disaster occurs. It is not acceptable to merely store information on a cell or smartphone. Have a clear concise, complete backup plan.

The Security Plan is expected to show ways of protection from access to the premises by employees. It also requires records and how each employee can access data. In addition, levels of access are to be delineated.  There should be power on authentications and auto-locks. CEs are expected to test and revise their contingency plans taking steps to identify and mitigate areas of weakness.

Employees should be aware that not just patient names are identifiers. PHI also includes addresses, phone numbers, drivers license numbers, medical record numbers, policy and account numbers, VIN numbers, health plan numbers, and relative name and identifiers.

Lastly, the HIPAA Security Plan must be in writing and the industry standard is an annual review (though there is no frequency statute). The Plan should have detailed policies and procedures with all incidents recorded, identifying a Disaster Plan with contingencies and technological interventions planned.

To read more about HITECH, please refer to Federal Register/Vol 75, No. 134/Wednesday, July 14, 2010/Proposed Rules

Department of Health and Human Services, Office of the Secretary

45 CFR Parts 160 and 164

Modifications to the HIPAA Privacy, Security, and Enforcement Rules Under the Health Information Technology for Economic and Clinical Health Act

Agency: Office for Civil Rights

Social and Professional Media

Social media is one of the most dangerous of risks. What an interesting dichotomy: on one hand we, in health care, are operating under increasing rigid privacy restrictions and on the other, individuals are posting the most intimate or the most mundane information about themselves and others on the internet for the world to read and see forever.

Agencies that allow clinicians to use their personal smart phones to take pictures of wounds and upload them to a patient record may need to be concerned about patient information stored on a personal cell phone. Who owns the data? Who will protect the data? Is texting a safe way to transport patient data? Experts say, “No.”

Should clinicians worry that their party and beer drinking pictures could be used against them if they are involved in a med error or a law suit?

At the VA, a new social media directive covers the use of Facebook pages, Twitter feeds, blogs, and YouTube channels. They use examples of these sites to educate personnel re personal and professional responsibilities.

100% of the Top 100 firms employ personnel to monitor social media. Every person interviewed has their social media investigated. Hiring is dependent upon the findings. Law firms, banks, accounting firms use social media investigators. Garner Consulting and TechCrunch Blog state “the new social media customer relationship management market (CRM) is expected to reach over $1 billion in revenue by the end of 2012, up from approximately $625 million in 2010. World-wide social CRM is projected to total $820 million in 2011.”

What are the ethics of making negative comments about a present or prior employer? Many organizations, especially banks, hospitals, and academic institutions are monitoring what is said about them and their clients or patients. They have clear policies reflecting training as to HIPAA. If an employee or former employee breaches a confidence, they may be sanctioned or sued.

WHAT Can You Do?

Encrypt email with patient or other sensitive data!

Be certain your organization has a strong corporate compliance plan in place. Have a strong Corporate Compliance Officer who reports to the CEO and Board of Directors. Consider the CCO having direct access to corporate counsel.

Have compliance policies and procedures that also address disaster preparedness, social media, data protection and backup. Annually, minimally, review the Corporate Compliance Plan. Keep a copy of the presentation with an attendance sheet to demonstrate corporate wide support of the plan. Be clear as to internal audits conducted as well as a corporate wide risk analysis conducted annually.

Review the American Nurses Association’s Principles for Nurses re Social Media and Social Networking. Draw from the ANA’s Code of Medical Ethics. Review the American Physical Therapy Association Code of Ethics. Many clinical associations can provide ethical guidelines that can assist with policy development.

Mayo Clinic has refined policies on social media well worth reading. Protect your agency. Be certain your employees know your agency’s ethical stance. Review regulations frequently:

http://www.govinfosecurity.com

http://www.mobilhealthnews.com

http://www.hhs.cms.gov

http://www.healthdatamanagement.com

Expect clinicians to adhere to their Standards of Practice. Expect everyone to adhere to the best practices in ethical protection of patient data.  Password  protect and change them frequently.

Be serious and state your ethical beliefs, in front of employees, frequently. Encourage employees that when in doubt…don’t. Don’t send data that causes them to hesitate. Encourage them to double check what is being sent to whom.

Ethics and Compliance have become the watchwords for a safer healthcare environment. Remember agencies with similar beliefs seek each other out. The ethical industry leader wants to work with other industry organizations that share the concern to protect, care, and achieve expected patient outcomes in a compliant ethical manner. Have a great 2012.

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Posted in CMS, CMS Guidelines, Compliance, CY2012, HIPAA, HIPPA HITECH, Home Health, Medicare | No Comments »

The 2012 Home Health Prospective Payment System (HHPPS) Final Rule

Friday, December 23rd, 2011

The changes are soon upon us as 2012 soon arrives.

The Federal Register published Nov. 4, 2011 provided the final rule that updates the home health prospective payment system (PPS) rates for 2012.

The notice identifies changes to the national standardized 60-day episode rates and per visit LUPA rates based on the market basket update and the case-mix creep adjustment. Additionally, this rule includes notable changes to the HH PPS case-mix system

As mandated by the Patient Protection and Affordable Care Act, the payment updates for 2012 include a 1.4 percent update factor to the episode rates, which reflects a 1 percent reduction applied to the 2.4 percent market basket update factor,

Average Episode Payment Rate Timeline

These episodes will then be reduced by 3.79 percent for case mix creep, resulting in an overall episode and per visit reduction of 2.39 percent. An additional 3 percent will be applied to payments for services to patients in rural areas based on the Congress-approved rural add-on. Be aware that agencies failing to submit required quality date will be subject to a reduction of 2 percent to their episodes and per visit payments.

The Centers for Medicare and Medicaid Services (CMS) will apply the CY 2012 HH PPS payment rates for episodes with claim statement “through” dates on or after Jan. 1, 2012, and on or before Dec. 31, 2012.

The 2012 national standardized episode payment will be $2,138.52, prior to case-mix and wage adjustments, as compared to 2011’s $2,192.07.

The table below gives a more detailed comparison:

National standardized episode rate for agencies submitting quality data
2011 national standardized episode payment rate Multiply by the 2012 payment update percentage of 1.4 percent Reduce by 3.79 percent for nominal case-mix change 2012 national standardized episode payment rate (urban) Rural (multiply by 3 percent rural add-on: x 1.03)
$2,192.07 x 1.014 x 0.9621 $2,138.52 $2,202.68

Case-Mix System Changes

The case mix system 2012 changes identify removal of two hypertension codes – 401.1 benign essential hypertension, and 401.9 unspecified essential. Coders will need to be very careful that clinician written “renal failure” or “renal insufficiency” in a record for a hypertensive patient requires a query to the physician to be certain the insufficiency/failure is chronic as that is the only way they will garner their HTN points in 2012.

Policy changes in the CY 2012 HH PPS final rule related to the case-mix system will be effective beginning with episodes with OASIS M0090 dates of Jan. 1, 2012.

Therapy

Because of the presenting patterns of therapy utilization over the past few years, payments impacted by therapy have been revised by CMS. Lower therapy cases seem to be encouraged. Payment for higher-therapy episodes is reduced, while payment for lower-therapy episodes is increased.

The case-mix model has five steps:

  • Step 1: First and second episodes, 0-13 therapy visits
  • Step 2: First and second episodes, 14-19 therapy visits
  • Step 3: Third episodes and beyond, 14-19 therapy visits
  • Step 4: Third episodes and beyond, 0-13 therapy visits
  • Step 5: All episodes with 20+ therapy visits

The revision seems to be indicating that the industry may have been providing more therapy than was expected by CMS. The changes also parallel payment with costs and redistribute dollars from high therapy payment groups to other case-mix groups.

Prepare Now

Change in regulation means a need for updated policies and procedures. Do not forget to alter your casemix list for coders. Be certain everyone understands the changes in therapy reimbursement. Therapy visit numbers should correlate to the OASIS integrated assessment identification for need.

Remember, CMS expects the changes to this rule to decrease payments to agencies by over $425 million dollars. It is essential that agencies are very efficient in assessment, care, and documentation.

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