Summary of the Final CY2011 Home Health Payment Rule

Finally we can get some insight for next years proposed changes

With the upcoming changes coming soon for the new year. Select Data took the time and compiled for you a list that we believe will affect agencies the most.

For detailed information on any of these topics, please refer to the 550 page Final Rule or the November 17, 2010 Federal Register.

Payment Rates and Market Basket:

• • CMS will implement a 3.79% reduction to the national standardized episodic rate for CY2011.
  • Market Basket Index increase will be 2.1% not 2.4% (1 point MBI adjustment). CMS is reviewing the methodology to be used in 2012.
  • $2,192.57 will be the 2011  non-rural base episode rate
  • $2257.83 will be the  2011 rural bases episodic rate

Non Routine Supplies (NRS)

• • See page 235 of the Final Rule for a complete text
  • CMS will defer the 3.9% case mix reduction to the NRS payment for 2011 as they have contracted with an independent group to review case mix and various NRS models.
  • The NRS conversion factor is to be updated in CY2011 by a market basket update of 1.1% and adjusted in outlier payments as per the Affordable Care Act . That conversion factor is $52.54.

Outliers:

• • Outlier payment is annually set at 5% but only 2.5% is spent on outliers. (2.5% was shifted from the base rate as it was for 2010 only)
  • The 10% agency level outlier cap continues in CY2011.

Case Mix:

• • CMS is phasing in the Case Mix reductions and will be applying the 3.79% reduction to HHPPS rates in 2011.  NOTE: Rural agencies will receive an additional 3% rural add-on beginning episodes/visits ending on or after April 1, 2010 and before 2016, which can assist to offset case mix reductions.

Hypertension:

• • Hypertension codes 401.1 and 401.9 remain case-mix diagnoses . CMS is conducting further research to determine if these codes impact the course of care and outcomes.

LUPA:

• • The add-on to the LUPA payment to HHAs that submit the required quality data will be updated by the HH market basket update of 1.1%.  See page 228 of the final rule.

Capitalization:

• • Agencies will be required to maintain capitalization during the three month period following the receipt of the provider number from CMS.

Therapy:

• • • CMS is concerned re growth of therapy services. CMS contends that the coverage requirements do not constitute additional responsibilities, but clarify existing responsibilities of the qualified therapist. Qualified therapist is defined as a PT, OT, or S/LP.
    • The therapy evaluation requirements will be mandatory April 1, 2011. The qualified therapist (not a COTA or PTA) is to evaluate progress as to goals, successive comparisons, needs for qualified therapy, and goals that remain for the next group of visits. Treatment goals are required to be described clearly in the treatment plan. The clinical record is to demonstrate the method used to assess function with objective measurement and successive comparison of measurement.
    • An evaluation/assessment is to be completed every 30 days and standardized tests must be used throughout the care. The reassessments are to be completed on therapy visits 13 and 19. There must be a correlation between the illness and professional standards.
    • CMS believes many agencies have not been in compliance with documentation requirements and therapist oversight.

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Home Health Face-to-Face encounter is a condition for payment:

• • • • Face to Face encounter information can be found on page 296 of the final rule. This requirement is mandated by the Affordable Care Act and CMS cannot change this mandate. It is implemented as of January 1, 2011,  but they clarified the timeline. The patient must have been seen by the certifying doctor within 90 days prior to start of episode and if not, they have 30 days to see the physician.
      • The physician must document on the certification how the clinical findings of the encounter support eligibility requirements as well as primary focus of home care. See page 498-500 of the rule.
      • Note: the law requires the physician to document that a face-to-face encounter occurred prior to certifying HH eligibility as a condition of payment.

Hospice Face-to-Face encounter:

• • • • A written attestation that a face-to-face encounter with the hospice patient has occurred is now required. CMS states the face-to-face requirement is part of the recertification and thus an administrative activity included in the per diem rate.
      • The face-to-face attestation and signature must be on either a separate and distinct addendum form to the recertification form or in a distinct area of the form. The area should include the physician’s comments, signature, date signed, and the benefit period dates for both certification and recertification periods. The narrative attestation is to be placed above the physician’s signature.
      • The encounter is to occur 30 days prior to the 180th day of recertification and each subsequent period.
      • The wording from the proposed rule to the final rule has changed to allow the face-to-face encounter to include a physician or nurse practitioner. However, the Affordable Care Act prohibits NPs from certifying or recertifying hospice patients. Hospices can employ (must receive a W2 or be a volunteer) Nurse Practitioners to conduct face-to-face encounters.
      • CMS suggests two ways to verify election periods: the ELGH and Health Insurance Query for Home Health Agencies (HIQH). If there is uncertainty re the Common Working File (CWF), agencies are advised to contact their MAC.  Also, the agency or the billing company may use the HIPAA Eligibility Tracking System (HETS) referring to transaction 270/271. Go to http:/?www.cms.gov/HETS/Help.

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Outcome Measures Deleted:

• • • • Discharge to community,
      • Improvement in urinary incontinence,
      • Emergent care for wound infections, and
      • Deteriorating wound status.

Outcome Measures Changed:

• • • • Improvement in bed transferring to replace improvement in transferring.
      • Emergency department use without hospitalization replaces “emergent care.”

The new OASIS-C process measures are finalized for HH Compare:

• • • • Timely initiation of care
      • Influenza received
      • PPV ever received
      • Heart failure s/s addressed during short term episodes
      • DM foot care and education in short term episodes
      • Pain assessment conducted
      • Pain interventions implemented in short term episode
      • Depression assessment conducted
      • Drug education on all medications provided to patient during short term episodes
      • Falls risk assessment for patients 65 and older
      • Pressure ulcer prevention plans implemented
      • Pressure ulcer risk assessment conducted
      • Pressure ulcer prevention included in POC

New G Codes:

• • • • • New G-code for services involving management and evaluation on the plan of care.
        • Separate G-code for observation and assessment of a patient’s condition while treatment is stabilized.

36 Month CHOW Rule clarification:

• • • • • CMS has noted that any change in majority ownership within 36 months after the effective date of the HHA enrollment in the Medicare program. The changes include mergers, asset sales, stock transfers, mergers, and consolidations for not for profit and not for profit entities.
        • CMS has identified they do not believe that a bankruptcy exception is needed.
        • Exceptions do include
          • Publicly- traded corporations with cost reports for 5 years.
          • HHA parent that is involved in an internal restructuring
          • Change of an existing business structure but the owners are essentially the same
          • Death of an owner

HHCAHPS :

• • • • • CMS anticipates the first reporting of HHCAHPs data  Q3 2011.
        • Dry run data is to be submitted to HHCAHPs Data Center by 1/21/2011.
        • The mandatory period of data collection for the CY2012 includes dry run data of data of Q3 2010, data of Q4 2010, and Q1  2011.
        • An exemption may be granted if an agency has less than 60 patients but they must comply with reporting requirements.
        • if an agency does not participate they risk a  penalty of MB minus 2%.

Value-Based Purchasing:

• • • • • The Affordable Care Act  requires CMS to outline a Value Purchasing Plan for Home Health Agencies, to be reported to Congress by 10/1/2011.
        • CMS states “it is premature to link a Pay for Performance system to OASIS at this time.”

Future Topics to Consider:

• • • • • • CMS is evaluating the assigning of HIPPS codes at the time of claims processing.
          • CMS is assessing this feasibility so it would no longer require grouper software use to assign HIPPS codes to the OASIS assessments.

Finally we can get some insight for next years proposed changes

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