Viewing posts categorised under: Payment Rate Updates

Prepping for PDGM

Admin
0 comments
Clinical Practices, Coding, Payment Rate Updates, PDGM

Prepping for PDGM

PPS final rule increases agencies' payments for 2019, finalizes PDGM

 
Now in the third week of January, 2019 and the PDGM model will be here in less than a year. Medicare-certified home care agencies need to begin NOW to prepare for the 2020 transition to a Patient-Driven Groupings Model. The proposed PDGM model, required by the Bipartisan Budget Act of 2018, is intended to remove current incentives to over-provide therapy services and changes the 60-day episode of care unit of payment to 30 days according to CMS. Also, a new set of groupings for the patient – diagnosis and functional levels – will be introduced that determines the patient’s reimbursement for the new 30-day episode. The PDGM model is planned for implementation on January 1, 2020 (Harris, 2018). Home care agencies should focus on several areas within their agency in order to prepare for PDGM. The fits area of concern should be the referral systems. According to Home Health Care News' Kaitlyn Mattson, "CMS’ move to shake up case mix specifically in regard to referral source is, at least in part, due to data and the agency’s belief that patients coming from institutional settings are typically sicker and, thus, need more care and resources." Moreover, "“60% of referrals come from the community,” Gina Mazza, director of the regulatory and compliance division at Fazzi Associates, told HHCN. “Every agency needs to understand how they specifically will be impacted by this new payment model. This is an area agencies really need to think about—what’s my patient population look like? Where do my referrals come from? Are there opportunities for me to make any changes?” Mazza added, “Referral source is always an area agencies want to work on, cultivate” (Mattson, 2018). Another area is staff education which is key to smoother PDGM transitions. Supporting on-the-ground staff may be the key to an easier PDGM transition. “Having the resources available to do the education—to stay on top of making sure nurses understand and are able to still spend the amount of time they want with their patients while fulfilling all the new requirements [will be paramount],” Susan Adams, vice president and administrator at Masonicare Home Health and Hospice (Mattson, 2018). Now finalized by CMS, there will be a learning curve with PDGM until staff becomes more comfortable with the intricacies of the rule. Agencies need to set aside a significant amount of time and attention so they can work with staff, so that assessments and documentations are really tight, Joy M. Cameron, vice president of policy and innovation at ElevatingHom said (Mattson, 2018). Confused? Frustrated? Not sure where to begin prepping for PDGM? Don't worry. SelectData has you covered. Contact our Business Development team to find out how SelectData can help you smoothly transition into PDGM today! Call 800-332-0555 or email info@selectdata.com and ask about our PDGM solution today! Resources Harris, T. (2018). OASIS-D GG0100B OASIS Home Health - Prior Mobility Functioning and Physical Therapy. Home Health Blogger. Retrieved from: http://go.myhomecarebiz.com/blog/oasis-d-gg0100b-prior-mobility-functioning-is-the-key-indicator-for-physical-therapy Mattson, K. (2018). PDGM Likely to Shake Up Patient Populations for Home Health Agencies. Home Health Care News. Retrieved from: https://homehealthcarenews.com/2018/08/pdgm-likely-to-shake-up-patient-populations-for-home-health-agencies/

Read more

Hospice Wage Index and Hospice Pricer for FY 2016

Admin
0 comments
Hospice, Payment Rate Updates

Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2016

The FY 2016 payment rates will be increased by 1.6 percent. The 1.6 percent hospice payment update is equivalent to the FY 2016 hospital market basket update (2.4 percent) less a productivity adjustment of 0.5 percentage point, less 0.3 percentage point. The productivity adjustment and 0.3 percentage point reduction are both mandated by section 3401(g) of the ACA. Beginning in FY 2014, hospices which fail to report the required quality data will have their market basket update reduced by 2 percentage points.

 

Hospice Wage Index and Hospice Pricer for FY 2016 Updates

Between October 1, 2015 and December 31, 2015, hospices will continue to be paid a single RHC per diem payment amount. Effective January 1, 2016, two separate payment rates will be applicable for RHC. A higher RHC rate for days 1 through 60 and a lower RHC rate for days 61 and beyond of a hospice episode of care will replace the single RHC rate. For hospice patients who are discharged and readmitted to hospice within 60 days of that discharge, a patient’s prior hospice days would continue to follow the patient and count toward his or her patient days for the new hospice election. The hospice days would continue to follow the patient solely to determine whether the receiving hospice would receive payment at the day 1 through 60 RHC rate or day 61 and beyond RHC rate. We will calculate the patient’s episode day count based on the total number of days the patient has been receiving hospice care separated by no more than a 60 day gap in hospice care, regardless of level of care or whether those days were billable or not. This calculation would include hospice days that occurred prior to January 1, 2016. An episode of care for hospice RHC payment purposes is a hospice election period or series of election periods separated by no more than a 60 day gap in hospice care.

Effective January 1, 2016, a service intensity add-on (SIA) payment may be provided for RHC days when direct patient care is provided by a registered nurse (RN) or social worker during the last seven days of the patient's life. The SIA is a payment that may be made in addition to the per diem rate for the RHC level of care. The SIA payment will equal the Continuous Home Care (CHC) hourly rate multiplied by the hours of nursing/social work service (for at least 15 minutes and up to 4 hours total) that occurred on a RHC day during the last seven days of life.

The FY 2016 hospice payment rates are effective for care and services furnished on or after October 1, 2015, through September 30, 2016. The hospice payment rates are discussed further in Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, Processing Hospice Claims, Section 30.2. The updated payment rates are shown in the attached tables. (CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 3345, Change Request 9301, Dated September 4, 2015)

 

Background of Hospice Payment Rates

Payment rates for hospice care, the hospice aggregate cap amount, and the hospice wage index are updated annually. The law governing the payment for hospice care requires annual updates to the hospice payment rates. Section 18149i)(1)(C)(ii) of the Social Security Act (the Act) stipulates that the payment rates for hospice care for fiscal years after 2002 will increase by the market basket percentage increase for the fiscal year (FY). This payment methodology has been codified in regulations found at 42 CFR §418.306(a) and (b).

The hospice aggregate cap amount is updated annually in accordance with §1814(i)(2)(B) of the Act and provides for an increase (or decrease) in the hospice cap amount. Specifically, the cap amount is increased or decreased for accounting years after 1984 by the same percentage as the percentage increase or decrease, respectively, in the medical care expenditure category of the Consumer Price Index for all Urban Consumers.

The hospice wage index is used to adjust payment rates to reflect local differences in wages. The hospice wage index is updated annually as discussed in hospice rulemaking. The FY 2010 Hospice Wage Index final rule finalized a provision to phase out the budget neutrality factor (BNAF) over seven years. The BNAF was reduced by 10 percent in FY 2010 and by an additional 15 percent in each of the next six years. For FY 2016, the BNAF is reduced by the final 15 percent reduction and, therefore, completely phased out. The hospice wage index is still adjusted by the hospice floor adjustment.

Section 3004 of the Affordable Care Act (ACA) amended the Act to authorize a quality reporting program for hospices. Section 1814(i)(5)(A)(i) of the Act requires that beginning with FY 2014 and each subsequent FY, the Secretary shall reduce the market basket update by 2 percentage points for any hospice that does not comply with the quality data reporting requirements with respect to that FY. (CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 3345, Change Request 9301, Dated September 4, 2015)

Policy of Hospice Payment Rates

The annual hospice payment updates will be implemented through the Hospice Pricer software found in the intermediary standard systems. The new Pricer module will contain new logic related to a service intensity add-on (SIA) payment. The SIA payment and related changes will be implemented through a separate instruction. An updated table will be installed in the module, to reflect the FY 2016 hospice wage index. (CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 3345, Change Request 9301, Dated September 4, 2015)

Summary of Hospice Payment Rates

This Change Request (CR) updates the hospice payment rates, hospice wage index, and Pricer for FY 2016. The CR also updates the hospice cap amount for the cap year ending October 31, 2015. These updates apply to Pub 100-04, Chapter 11, Section 30.2 (CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 3345, Change Request 9301, Dated September 4, 2015)

Frequently Asked Questions

What is the FY 2016 Hospice Payment Rate for RHC for October 1, 2015 through December 31, 2015?

Code Description FY 2016 Payment Rate Labor Share Non-Labor Share
651 Routine Home Care $161.89 $111.23 $50.66

What is the FY 2016 Hospice Payment Rates for RHC for January 1, 2016 through September 30, 2016?

Code Description FY 2016 Payment Rate Labor Share Non-Labor Share
651 Routine Home Care (days 1-60) $186.84 $128.38 $58.46
651 Routine Home Care (days 60+) $146.83 $100.89 $45.94

What are the FY 2016 Hospice Payment Rates for CHC, IRC, and GIP?

Code Description FY 2016 Payment Rate Labor Share Non-Labor Share
652 Continuous Home Care 652 Full Rate = 24 hours of care $=39.37 FY 2016 hourly rate $944.79 $649.17 $295.62
655 Inpatient Respite Care $167.45 $90.64 $76.81
656 General Inpatient Care $720.11 $460.94 $259.17

What is the FY 2016 Hospice Payment Rate for RHC for October 1, 2015 through December 31, 2015 for Hospices That DO NOT Submit the Required Quality Data?

Code Description FY 2016 Payment Rate Labor Share Non-Labor Share
651 Routine Home Care $158.70 $109.04 $49.66

What are the FY 2016 Hospice Payment Rates for RHC for January 1, 2016 through September 30, 2016 for Hospices That DO NOT Submit the Required Quality Data?

Code Description FY 2016 Payment Rate Labor Share Non-Labor Share
651 Routine Home Care (days 1-60) $183.17 $125.86 $57.31
651 Routine Home Care (days 60+) $143.94 $98.90 $45.04

What are the FY 2016 Hospice Payment Rates for CHC, IRC, and GIP for Hospices That DO NOT Submit the Required Quality Data?

Code Description FY 2016 Payment Rate Labor Share Non-Labor Share
652 Continuous Home Care 652 Full Rate = 24 hours of care $=38.59 FY 2016 hourly rate $926.19 $636.39 $289.80
652 Inpatient Respite Care $164.15 $88.85 $75.30
652 General Inpatient Care $705.93 $451.87 $254.06

What is the List of CBSA codes that are invalid for Hospice for FY 2016 due to the wage index transition (these areas need to use 50xxx codes)?

CBSA Code CBSA Name
10380 Aguadilla-Isabela, PR
11100 Amarillo, TX
12060 Atlanta-Sandy Springs-Roswell, GA
12260 Augusta-Richmond County, GA-SC
13140 Beaumont-Port Arthur, TX
13740 Billings, MT
13980 Blacksburg-Christiansburg-Radford, VA
14010 Bloomington, IL
14540 Bowling Green, KY
15764 Cambridge-Newton-Framingham, MA
16740 Charlotte-Concord-Gastonia, NC-SC
16820 Charlottesville, VA
17140 Cincinnati, OH-KY-IN
18140 Columbus, OH
18880 Crestview-Fort Walton Beach-Destin, FL
19660 Deltona-Daytona Beach-Ormond Beach, FL
20524 Dutchess County-Putnam County, NY
21060 Elizabethtown-Fort Knox, KY
21340 El Paso, TX
23104 Fort Worth-Arlington, TX
24340 Grand Rapids-Wyoming, MI
24860 Greenville-Anderson-Mauldin, SC
25060 Gulfport-Biloxi-Pascagoula, MS
26580 Huntington-Ashland, WV-KY-OH
26820 Idaho Falls, ID
26900 Indianapolis-Carmel-Anderson, IN
29180 Lafayette, LA
31140 Louisville/Jefferson County, KY-IN
31180 Lubbock, TX
31540 Madison, WI
32820 Memphis, TN-MS-AR
33260 Midland, TX
33460 Minneapolis-St. Paul-Bloomington, MN-WI
34820 Myrtle Beach-Conway-North Myrtle Beach, SC-NC
34980 Nashville-Davidson--Murfreesboro--Franklin, TN
35084 Newark, NJ-PA
35380 New Orleans-Metairie, LA
35614 New York-Jersey City-White Plains, NY-NJ
36260 Ogden-Clearfield, UT
37460 Panama City, FL
38660 Ponce, PR
39660 Rapid City, SD
40340 Rochester, MN
40380 Rochester, NY
41540 Salisbury, MD-DE
41980 San Juan-Carolina-Caguas, PR
43340 Shreveport-Bossier City, LA
43580 Sioux City, IA-NE-SD
43900 Spartanburg, SC
44060 Spokane-Spokane Valley, WA
46220 Tuscaloosa, AL
47260 Virginia Beach-Norfolk-Newport News, VA-NC
47380 Waco, TX
47894 Washington-Arlington-Alexandria, DC-VA-MD-WV
48620 Wichita, KS
49180 Winston-Salem, NC
49340 Worcester, MA-CT
99901 Alabama
99913 Idaho
99915 Indiana
99917 Kansas
99918 Kentucky
99922 Massachusetts
99923 Michigan
99925 Mississippi
99926 Missouri
99934 North Carolina
99936 Ohio
99945 Texas
99946 Utah
99949 Virginia
99951 West Virginia

What is the Hospice Cap?

The hospice aggregate cap amount for the 2015 cap year ending October 31, 2015 is $27,382.63. In computing the cap, CMS used the medical care expenditure category of the March 2015 Consumer Price Index for all Urban consumers, published by the Bureau of Labor Statistics (http://www.bls.gov/cpi/home.htm), which was 444.020.

What is the Hospice Wage Index?

Following publication of the FY 2016 Hospice Wage Index and Payment Rate Update in the Federal Register, the revised payment rates and wage index will be incorporated in the Hospice Pricer and forwarded to the Medicare contractors

On February 28, 2013, the Office of Management and Budget (OMB) issued OMB Bulletin No. 13-01, announcing revisions to the delineation of MSAs, Micropolitan Statistical Areas, and Combines Statistical Areas, and guidance on uses of the delineation in these areas. These revisions will be incorporated into the hospice wage index for FY 2016.

In order to provide a transition to the revised geographic area delineations, CMS will use a blended wage index for hospice payments for one year (FY 2016). The transition wage index is a 50/50 blend of the wage index values using OMB's old area delineations and the wage index values using OMB's new area delineations. That is, for each county, a blended wage index is calculated equal to fifty percent of the FY 2016 wage index using the old labor market area delineation and fifty percent of the FY 2016 wage index using the new labor market area delineation. This results in an average of the two values. The hospice floor calculation is applied to the wage index values prior to blending.

Due to the way that the transition wage index is calculated, some Core Based Statistical Areas (CBSAs) and statewide rural areas will have more than one transition wage index value associated with that CBSA or rural area. However, each county will have only one transition wage index. For counties located in CBSAs and rural areas that correspond to more than one transition wage index value, the CBSA number will not be able to be used for FY 2016 claims. These CBSA numbers are listed in Table 7 (attached). In these cases, a number other than the CBSA number will be needed to identify the appropriate wage index value for claims for hospice care provided in FY 2016. These numbers are five digits in length and begin with “50”. These special 50xxx codes are shown in the last column of the FY 2016 hospice wage index file located at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html. For counties located in CBSAs and rural areas that still correspond to only one wage index value, the CBSA number will still be used. (CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 3345, Change Request 9301, Dated September 4, 2015)

Helpful Tip


Don’t forget to determine which the FY 2016 Hospice Payment Rate for RHC applies; October 1, 2015 through December 31, 2015 or after January 1, 2016 through September 30, 2016.

Read more

Hospice Wage Index and Payment Rate Update: FY2014

Admin
0 comments
Compliance, Payment Rate Updates

The CMS proposed rule “Medicare Program; FY2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform.” was released April 29, 2013. Though the rule includes no proposed changes for payment reforms presently, it does outline the findings from ongoing data collection, analysis, and provides certain choices being considered for future consideration and review. One of the most frequently asked questions, per CMS, is “When will Medicare Administrative Contractors (MACs) begin returning to provider (RTP) hospice claims that have ‘adult failure to thrive’ or ‘debility’ as the principle diagnosis?” CMS has stated “Soon.”

Old Rule Enforcement Dates

Hospices that attempt to submit more than one claim per hospice beneficiary per month will have claims returned beginning on dates of service July 1, 2013. This has been a requirement not reinforced, but will have increased reinforcement, per the January 31, 2013 transmittal

New Proposed Rule

For fiscal year (FY) 2014, CMS currently anticipates hospice payments to increase, on average, a net of 1.1 percent based on  the anticipated fiscal year (FY) 2014 hospital market basket update (currently projected at 2.5 percent), reduced by 0.7 percentage points due to reductions mandated by the Affordable Care Act (ACA).  Note that CMS reserves the right to notify the industry this summer of a potential re-estimation of the hospital market basket and the changes identified in the Affordable Care Act (ACA). However, Hospices that failed to report quality measures required under the Hospice Quality Reporting Program (HQRP) earlier this year would have their market basket values further reduced by 2%.

Levels of Care Estimated Payment Rates

Both the Department of Justice and the OIG are monitoring hospices with long lengths of stay at a general inpatient (GIP) level of care. CMS has an even higher focus of care if GIP is provided in inpatient units of hospice. Given this fact and many others, CMS included as part of the proposed rule estimated FY2014 payment rates for the four payment categories under hospice. Note the table includes the projected payment rates:

Proposed FY2014 Hospice Payment Rates

Codes Description FY2013 payment Rates Multiply by the FY2014 proposed hospice payment update of 1.8 percent FY2014 Proposed Payment Rate Labor Share of the proposed payment rate Non-labor share of the proposed payment rate
651 Routine Home Care $153.45 x1.018 $156.21 $107.33 $48.88
652 Continuous Home CareFull rate=24 hours of care$=37.99 hourly rate $895.56 X1.018 $911.68 $626.42 $285.26
655 Inpatient Respite Care $158.72 x1.018 $161.58 $87.46 $74.12
656 General Inpatient Care $682.59 x1.018 $694.88 $444.79 $250.09
  You can find the FY2014 hospice wage index values at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html. Levels of care have been and will be an ongoing focus of scrutiny as seen by the CMS filing of a civil suit against one of the largest providers of hospice services, for “submitting false claims to Medicare for crisis care services that were not necessary, not actually provided, or not performed in accordance with Medicare requirements.”  Those requirements necessitate specific documentation. The old adage, “if you did not document it, you did not do it” has real meaning when an agency is attempting to defend itself in this kind of situation.

Old Rule Documentation Requirements.

Be cautious that your general inpatient levels of care (GIP) services documentation can withstand scrutiny: Prior to transfer to an inpatient setting, ask if the clinical team documented all attempted interventions in the non-inpatient setting and be certain they were documented specifically. Were caregivers involved? Since pain assessment and care is scrutinized, was documentation complete as it related to inpatient care justification? Be specific. Does pain medication administration require skilled clinical intervention not easily or safely completed in the home; ie tubing change? Intensive clinical intervention for significant change in condition such as pathological fracture would require specific documentation but may justify transfer. Also, once admitted to an inpatient setting, initiate the discharge planning process and document the plan. Identify who assisted with the careplan, as well as the expected date of discharge. Again, were caregivers involved?

Payment Reform

Though the proposed rule DOES NOTpropose payment reform changes at this time, CMS announced it will post the ABT Hospice Study Technical Report on the Hospice Center webpage. The proposed rule does state future consideration of several potential options for payment reform:
  • Use of the initial Medicare Payment Advisory Commission (MedPAC) proposed U-shaped model of March 2009 that oiutlined an increased payment at the beginning and end of an episode of care, with reduced daily payments in the center of the episode
  • A possible short-stay add-on to cover the higher costs of patients who are on service for a short time.
  • A possible tiered approach to payment with payment based on length of stay.
  • CMS is also looking at a potential case-mix based system. It is believed by some that is the reason for the stronger reinforcement of use of more than just a primary diagnosis stated on a claim. CMS stated a recent analysis showed that 4 of 5 hospice claims in 2010 only included the terminal diagnosis out of compliance with  ICD-9-CM coding guidelines. CMS has stated that “hospices need to use the ICD-9 coding guidelines when determining the principle diagnosis and all other diagnoses.” In hospice, as in home health, clear coding to the highest level of specificity paints a more complete portrait of the patient and their individualized needs.
A new edit is being considered, which would identify and reject claims without related diagnoses).

Rebasing of Routine Home Care

None proposed at this time Home Health and Hospices will need to start planning NOW for 2014.

Read more

What are the New Payment Methods?

Admin
0 comments
Frequently Asked Questions, Payment Rate Updates

There will be various types of risk sharing programs. There may be Value- based Payment plans. Expect to see ACOs lead by hospitals or physician groups. Home Health Agencies will need to show value to become a part of such collaborative formalized groups.  Expect CMS to utilize comparative-effectiveness techniques of evidenced-based practices. Become familiar with the following terms:

ACOs

Integration of providers to assume responsibility for the quality, costs, and outcomes of care. Accountable Care Organizations (ACOs) with Bundled Payments or Shared Savings Programs where the ACO shares risk.

Total Costs of Care

Reimbursable methodology that is being designed to reduce cost by person by episode.

Predictive Modeling

A methodology to estimate how clients may use services and the related costs based upon variables, prior behavior, and attributes assigned.

Transition of Care

The movement of patients from one health care practitioner or setting to another as the condition and care needs change. Under this model, there will be NO discharge summary. Instead expect a “Transition Summary”.

Read more

Learn How

Select Data can improve your agency's productivity while increasing your profitablility...

370x275

WATCH DEMO

Article Categories