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CMS Updates Pricer to Support Value Based Purchasing Model

New Payment Adjustments to HHA’s

 

The 2016 Home Health Prospective Payment System (HH PPS) final rule required the implementation of the Home Health Value Based Purchasing (HHVBP) Model in nine states that represent each geographic area in the United States. All Medicare-certified HHAs that provide services in Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee and Washington will have their payment adjusted based on the HHA’s total performance score on a set of measures already reported with the Outcome and Assessment Information Set (OASIS) and the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) for all patients serviced by the HHA. Three new measures are included in which performance points are achieved for reporting data.

The HHVBP Model, now finalized, will be tested by CMS and revisions are needed to update the HH Pricer program to accept the necessary adjustment factor and capture the adjusted amount on the claim record. MACs will place the HH VBP adjustment amount on the claim as a value code QV amount. This may be a positive or negative amount. The Pricer has been updated to reflect standardized payment amounts. CR 10167 requires that standardized amounts be calculated by Medicare systems and passed on to claims history databases using the field created for hospital standardized payment amounts. Standardized claims payment amounts are actual payment amounts adjusted to remove sources of variation not directly related to decisions to utilize care. Examples of these variations include hospital wage indexes, geographic cost indexes (GPCIs), incentive payment and penalty adjustments.
CR 10167 requires system changes to ensure HH and hospice claims processing are consistent. CR 6550 created edits on hospice claims to ensure that G-codes for service visits are reported with the corresponding revenue code for the service discipline. Editing does not exist for HH claims even though the same G-codes and revenue codes are required. The system has been updated to include these edits.

Providers should be aware that the MACs will return to the HHA the following claims:

  • Home health claims (TOB 032x other than 0322) reporting revenue code 042x if the HCPCS code is other than Q5001, Q5002, Q5009, G0151, G0157, or G0159
  • Home health claims (TOB 032x other than 0322) reporting revenue code 043x if the HCPCS code is other than Q5001, Q5002, Q5009, G0152, G0158, or G0160
  • Home health claims (TOB 032x other than 0322) reporting revenue code 044x if the HCPCS code is other than Q5001, Q5002, Q5009, G0153, or G0161
  • Home health claims (TOB 032x other than 0322) reporting revenue code 055x if the HCPCS code is other than Q5001, Q5002, Q5009, G0162, G0299, G0300, G0493, G0494, G0495, G0496
  • Home health claims (TOB 032x other than 0322) reporting revenue code 056x if the HCPCS code is other than Q5001, Q5002, Q5009, or G0155
  • Home health claims (TOB 032x other than 0322) reporting revenue code 057x if the HCPCS code is other than Q5001, Q5002, Q5009, or G0156

References
The official instruction, CR 10167, https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/2017Downloads /R3933CP.pdf

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