Viewing posts categorised under: Hospice

Hospice Quality Measures to be Publicly Reported

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Hospice, Legislation

Hospice Quality Measures to be Publicly Reported

Start Preparing now - Providers should review the data about their agency!

 
June 1, 2017, CMS plans to give preliminary reports in advance of the Hospice Compare launch to occur this summer.  These initial reports will include seven Hospice Item Set (HIS) quality measure results. The Hospice Quality Reporting Program (HQRP) currently has two requirements currently: the patient HIS and the CAHPS Hospice Survey. Medicare certified hospices must be in compliance with these two reporting requirements. A Bit of History The Affordable Care Act requires that the Secretary and CMS report Quality Measures provided by hospice programs on a CMS website. That website is to include the HIS Quality Measure results along with results from the CAHPS Hospice Survey. The public reporting is to begin in the summer, 2017 and be presented on the new Hospice Compare Website. The Site That site will reflect scores for each of the seven assessment-based Quality Measures (QM). Those seven measures include:
  • Treatment Preferences NQF 1641
  • Beliefs/Values Addressed (if desired by the patient) NQF 1647
  • Pain Screening NQF 1634
  • Pain Assessment NQF 1637
  • Dyspnea Screening NQF 1639
  • Dyspnea Treatment NQF 1638
  • Patient treated with an opioid who was given a bowel regimen NQF 1617
The Regulations The Affordable Care Act requires that agencies have the opportunity to preview the quality data before it is made public so, CMS has developed the Preview Reports which will reflect the data much like it will appear on the Hospice Compare.  They will be automatically generated and saved into the provider’s shared folder in the CASPER application. The reports will be available about 8 months after the end of each data collection period.  Providers will have 30 days to review the reports. Hospice Report Specifications include a report run date June 1, 2017 for a reporting period for HIS Quality Measures: Patients discharged October 1, 2015- September 30, 2016. Providers should review the data about their agency. If you have a question and want CMS to review the data you must follow the procedures found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Quality-Public-Reporting.html If a provider disagrees with the data contained within the preview report, they will have an opportunity to have CMS perform a review but all requests must be made within the 30 day preview period. For more information on CASPER Reporting Provider User Guidance see https://www.qtso.com/hospice train.html  or QIES technical help desk at help@qtso.com  1-877-201-4721.  Hospice Quality questions may be directed to the Quality Help Desk at HospiceQualityQuestions@cms.hhs.gov For your Hospice coding, document review, and billing needs, contact Select Data at 1-800-332-0555. Our All American based specialists are here to assist you as we have been assisting Hospice and Home Health agencies for over 25 years.

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Hospice and Medicare Part D: Get the Facts

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Hospice, OIG

Hospice and Medicare Part D: Get the Facts

Hospice and Medicare Part D: Get the Facts. New CMS Guidance.

 
Medicare Part D is a Federal program designed to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries.  In 2014 Medicare paid over 77 billion dollars in Part D benefits serving more than 37 million beneficiaries.  Part D administration depends on extensive coordination and information sharing between the Federal and State agencies, healthcare providers, drug plan sponsors, contractors and third-party payers. Hospice programs are required to provide individuals receiving Hospice care with drugs and biologicals related to the palliation and management of the terminal illness defined in the Hospice plan of care.  Medicare pays the Hospice agency for each day in which the patient is receiving hospice care, regardless of the amount of care received on a given day.    Hospice is a Medicare Part A benefit and drugs provided by the hospice are covered under the Medicare payment to the hospice program and not covered under Part D. Prescription drugs may be covered under the Part D benefit for the patient receiving Hospice care if the drug is unrelated to the terminal prognosis of the individual.   In 2012 the Office of the Inspector General (OIG) identified situations in which Medicare was paying twice for prescription drugs for hospice beneficiaries, and those beneficiaries may be paying unnecessary copayments for prescription drugs.  The report indicated that most hospice beneficiaries generally experience common symptoms during the end of life regardless of the terminal diagnosis.  These symptoms include pain, nausea, constipation and anxiety.  The OIG worked with the National Hospice and Palliative Care Organization (NHPCO) to identify 4 common categories of prescription drugs that are typically used to treat these symptoms:  antinauseants, laxatives, analgesics, and antianxiety drugs.  These categories of drugs should be covered under the Hospice benefit; however, some instances occur in which 1 or more of these drug categories may be unrelated to the terminal diagnosis of the beneficiary.  In these situations the Part D benefit is responsible for coverage of the drug and the patient assumes any copayment required. It is beneficial for the provider to understand the steps involved from the Medicare Part D plan sponsor in the coverage or rejection of the claim.
  1. Once the plan sponsor receives a pharmacy claim, for the beneficiary who has elected Hospice and the drug falls into the 4 common categories, the claim may be rejected using the National Council for Prescription Drug Programs (NCPDP)-approved reject coding.
Code Description
A3 This product may be covered under Hospice-Medicare A
75 Prior Authorization Required
569 Provide Notice:  Medicare Prescription Drug Coverage and Your Rights
2. Plan sponsors are required to provide a point of sale message that states: “Hospice Provider- Request Prior Authorization for Part D Drug Unrelated to Terminal Illness or Related Conditions” This message should also include the 24 hour pharmacy help desk number to call with questions. 3. The beneficiary, beneficiary’s representative, or prescriber may contact the plan sponsor to request a coverage determination.
  • The sponsor can contact the prescriber to complete the Prior Authorization (PA) form.
  • The prescriber can provide a verbal explanation to the sponsor as to why the drug is unrelated to the terminal illness or related conditions or complete the PA form and submit it to the sponsor by fax or mail.
  • If the prescriber is unaffiliated with the Hospice provider and is unable or unwilling to coordinate with the Hospice provider to provide the statement, the plan sponsor can contact the Hospice Provider for the statement that the drugs are unrelated to the terminal illness or related conditions or complete the PA form.
In some instances the plan sponsor may contact the Hospice provider and receive information that the drug is related to the terminal illness or related condition but it has been determined to be a beneficiary liability.  Once the plan sponsor has received the statement that a drug is unrelated to the terminal illness or related conditions the adjudication process can take no more than 24 hours for expedited requests or 72 hours for standard requests.  (Section 30.2 Chapter 18 Medicare Drug Benefit Manual) Beneficiary liability indicates that the patient is assuming responsibility for the cost of the drug.  Beneficiary liability can occur when the Hospice interdisciplinary group has determined, after discussion with the patient and family, that the existing medication/s may no longer be effective in the intended treatment and/or may be causing negative symptoms in the individual.  The medications would not be covered under the Medicare Hospice benefit as they would not meet the requirements of reasonable and necessary for palliation of pain and/or symptom management.  The patient may choose to have these medications filled through their pharmacy, if this occurs then the medications then become a beneficiary liability for payment and the cost of the medication would not be covered under Medicare Part D.  A patient may also request a drug for his/her terminal illness that is not included in the Hospice formulary and the beneficiary refuses to try a formulary equivalent first; or the drug has been determined by the Hospice provider to be unreasonable or unnecessary for the patient’s palliation of pain and/or symptom management.  The drug then becomes a beneficiary liability and no payment for the drug will be made under the Part D benefit. Hospice providers are encouraged to use the PA form prospectively to prevent the drug claim from rejecting at the point of sale for those drugs that fall into the 4 common categories that are unrelated to the terminal prognosis and the patient is prepared to obtain the drug.  Section II of the PA form is not required, however, as Part D plan sponsors complete retrospective reviews of medications covered under the Part D benefit that fall into the 4 common categories while the patient receives care under the Hospice benefit, the provider would find that incorporating the completion of section II in their practice would mitigate any questions in the future. The information covered in this article represents a fraction of the complexities associated with regulations that govern payment under Medicare benefits.  Select Data is dedicated to assisting your agency in answering these questions to enable you to meet the needs of your patients.  As an expert in the language of CMS, Select Data has over 25 years of preparation to service you.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more. Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Welcome to National Hospice & Palliative Care Month for November 2016!

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Hospice

Welcome to National Hospice & Palliative Care Month for November 2016!

Know Your Options! Hospice & Palliative Care.

 

“Know Your Options!” is the theme of this month’s celebration of hospice & palliative care services. The goal of this celebration is to bring awareness of the services that hospices provide to patients with life-limiting illnesses & their families as well as the importance of learning about your options of care before illness strikes.When a cure is not possible, hospice & palliative care services allow patients to live their lives surrounded by family & friends despite their illnesses while receiving the highest possible quality of care delivered by interdisciplinary teams with care focused on the physical & spiritual well-being of the patient. Hospice staff is available 24 hours a day, 7 days a week. Staff members provide not only hands-on patient care, but also any supply drugs, medical supplies and DME required to keep the patient comfortable. Spiritual care includes addressing the emotional & psychosocial aspects of dying for the patient & their family, as well as providing subsequent bereavement care & counseling. Available as a benefit to Medicare beneficiaries since 1986, hospice services are currently provided to 1.65 million patients every year. By providing care to patients with life-limiting illnesses in their home, free-standing hospice facilities or in an inpatient setting, hospice services have saved CMS approximately 2 billion dollars. As the benefits of hospice care are clear, we at Select Data ask that you join us in celebrating National Hospice & Palliative Care Month! To find out how Select Data can help you improve coding accuracy check out our OASIS review and coding services.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more.
 
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Hospice Documentation Checklist: Is Your Present Documentation at Risk?

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Clinical Practices, Coding, Compliance, Hospice

Hospice Documentation Checklist: Is Your Present Documentation at Risk?

Hospice Documentation Supports Your Agency's Services. Is Your Agency at Risk? Read this.

 

Supporting Hospice Documentation

Supporting Medicare Hospice Services requires proper documentation so an agency, when paid, retains that payment. The following list is a guide to assist Hospice agencies in that endeavor. It may not be all inclusive, but it provides to an agency a format to present the portrait of each patient and their specific needs. Select Data provides professional coding services to Home Health and Hospice agencies and are industry experts in the language of CMS. We assist agencies with the accurate representation of their patient. To find out how Select Data can help you improve coding accuracy check out our OASIS review and coding services. To download the Hospice Documentation Checklist fill out the information below

   
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more.
 
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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National Hospice Month: Know Your Options!

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Clinical Practices, Hospice

National Hospice Month: Know Your Options!

November's National Hospice and Palliative Care Month 2016.

 

November 4, 2016, the National Hospice and Palliative Care Organization (NHPCO) rallied a social media campaign for all Hospice providers and supporters to increase #HospiceAwareness (Nhpco.org, 2016). However, Select Data encourages the outreach of Hospice materials to be used all year round. Hospice documentation is on the hot seat! Hospice documentation and billing practices continue to face increased scrutiny by regulatory agencies, resulting in multi-million dollar fines.

Hospice services over 1.6 million patients in a report by NHPCO in 2014 (NHPCO.org, 2015). According to New Hampshire Leader, January 11, 2014, Hospice providers agrees to pay $150 million in settlements. The UT San Diego reported in June of 2013 that $112 million claim filed against SD Hospice. This is because "About 40% of hospice claims denied are due to documentation failing to support the terminal illness,"  stated Latesha Walker at the NAHC&H annual March on Washington Conference. Luckily, Select Data are experts in documentation review and Hospice coding. With over 20 years of experience in the Home Health and Hospice industry, Select Data is uniquely qualified to mitigate operational challenges. To find our more about our documentation review services click here or email us at info@selectdata.com.

Sources

National Hospice and Palliative Care Organization (2016). Hospice Month Resources. NHPCO.org. Retrieved from: http://www.nhpco.org/hospice-month-resources National and Palliative Care Organization (2014). NHPCO Facts and Figures on Hospice Care. NHPCO.org. Retrieved from: http://www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Figures.pdf
For a full review of these OASIS-C2 corrections and more, attend our free 30-minute Select Connects with Clinicians webinar on December 14, 2016. Click here to read more. Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Hospice and Palliative Care Awareness

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Clinical Practices, Hospice

Hospice and Palliative Care Awareness

November's National Hospice and Palliative Care Month 2016.

 
Philosophically, palliative care is the belief in patient and family-centered care that optimizes the quality of life by anticipating, preventing and treating suffering.  Palliative care addresses the physical, emotional, social, intellectual and spiritual needs throughout the course of illness.  Palliative care encourages patient autonomy through access to information and choice.  Four tenets drive the administration of palliative care.
  1. Care is provided and coordinated by an interdisciplinary team.
  2. Services are available concurrently with or independent of, curative or life-prolonging care.
  3. Patients, families, and care providers communicate and collaborate about care needs.
  4. Support, for the patient and family desires for peace and dignity is provided throughout the course of illness, during the dying process, and after death.
Hospice care is considered the model for quality care delivered in a compassionate manner for patients facing terminal illness.  Hospice provides pain management, expert clinical care, emotional and spiritual support tailored to the patients’ desires and needs.  The hospice model provides support to the patient’s loved ones as concern is with the patient’s holistic needs.  The focus of hospice is on caring not curing and care may be provided in the home, hospice facilities, skilled nursing facilities and other long term care facilities.  Hospice is covered under Medicare, Medicaid and most private insurance plans and is available to patients with a terminal illness of any age, religion or race.  Patients receiving the hospice benefit have increased from 25,000 in 1982 to 1,656,000 patients in 2014. Hospice and palliative care are philosophically quite similar.  The distinction between the two comes from the categorization of care type for billing purposes.  Palliative care is for anyone with a serious illness and can occur at any age or stage of illness.  Palliative care can occur along with curative treatment and is not dependent on prognosis.  Hospice is a benefit, traditionally provided through Medicare that provides palliative care for terminally ill patients who have six months or less to live.  People who receive the hospice benefit are no longer receiving curative treatment for their underlying disease.
For a full review of these OASIS-C2 corrections and more, attend our free 30-minute Select Connects with Clinicians webinar on December 14, 2016. Click here to read more.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Hospice Wage Index and Hospice Pricer for FY 2016

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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.

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G-Codes in Home Health and Hospice

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G-Codes, Hospice

G-Codes in Home Health and Hospice

Effective January 1, 2016, CMS established new G-codes to differentiate levels of nursing services provided during a hospice stay and a home health episode of care. These two G-codes and the retirement of G0154 will be effective for hospice dates of service on and after January 1, 2016 and for home health episodes of care ending on or after January 1, 2016: Service is provided by an RN shall be coded as G0299, Service is provided by an LPN shall be coded as G0300.

 

FY 2016 G-Code Policy Changes in Home Health and Hospice

Effective January 1, 2016, As described in CR 9201, CMS is implemented a Service Intensity Add-On (SIA) payment for skilled visits (provided by a registered nurse (RN) and/or medical social worker) provided during last seven days of life during a hospice election (in addition to the current per diem rate for the Routine Home Care (RHC) level of care). The SIA payment would be paid in addition to the current per diem rate for the RHC level of care.

The SIA policy necessitates the creation of two G-codes for nursing for use when billing skilled nursing visits (revenue center 055x), one for a RN and one for a Licensed Practical Nurse (LPN). During periods of crisis, such as the precipitous decline before death, patient needs intensify and RNs are more highly trained clinicians with commensurately higher payment rates who can appropriately meet those increased needs. Moreover, Medicare rules at §418.56(a)(1) require the RN member of the hospice interdisciplinary group to be responsible for ensuring that the needs of the patient and family are continually assessed. Medicare expects that at end of life, the needs of the patient and family will need to be frequently assessed; thus the skills of the interdisciplinary group RN are required. As such, the SIA policy was finalized to recognize additional payment at end-of-life for services provided by RNs and not LPNs.

In order to quantify the amount of RN services provided to a patient, hospice claims must differentiate between nursing services provided by an RN and nursing services provided by an LPN. Therefore, CMS established codes to distinguish between RN services [G0299] and LPN services [G0300]. The current single G-code of G0154 for “Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice setting” will be retired. Since G0154 is used in both the home health and hospice settings, home health agencies and hospices will be required to utilize G0299 for “direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting” and G0300 “direct skilled nursing of a licensed practical nurse (LPN) in the home health or hospice setting”.

History of G-Codes in Home Health and Hospice

The March 2009 Medicare Advisory Payment Commission (MedPAC) report recommended that CMS improve the HH PPS to mitigate vulnerabilities such as payment incentives to provide unnecessary services. The need for more specific resource use data to fully address these vulnerabilities was identified.

In their March 2010 report, MedPAC recommended that CMS improve the HH PPS, and expressed concern with the significant variation in the services provided to beneficiaries. MedPAC also suggested that CMS adjust the HH PPS case-mix weights to more accurately reflect services required. In order to address MedPAC’s concerns and to more fully understand the services which are being provided, they identified a need to collect additional data on the HH claim regarding the specific sorts of therapy and nursing services being provided. Specifically, a number of the new and revised codes described below differentiated between therapy services provided by a qualified therapist versus a therapy assistant. A qualified therapist is one who meets the personnel requirements in the Conditions of Participation (CoPs) at 42 CFR 484.4. Additionally, other new and revised codes were provided for the reporting of training and/or education of the patient or family member and the skilled nursing services of a licensed nurse for the management and evaluation of the care plan and the observation and assessment of the patient’s condition, when normal “direct” skilled nursing services of a licensed nurse are not provided.

Effective January 1, 2011, In order for CMS to collect more specific information regarding the sort of services provided to home health patients, CMS revised the current descriptions for existing G-codes for physical therapists (G0151), occupational therapists (G0152), and speech-language pathologists (G0153), to include in the descriptions that they are intended for the reporting of services provided by a qualified physical or occupational therapist or speech language pathologist.

CMS required Home Health Agencies (HHAs) to report additional and more specific data for therapy and nursing visits on the HH claim beginning January 1, 2011. While many of the codes (described below) included the hospice setting in their description, CMS did not require hospices to use of the G-codes described below at this time, as Medicare systems limitations prevented the use of the codes on hospice claims.. Future instruction was planned to expand the optional use of these codes to hospice claims. Existing codes that included the hospice setting in their description continued to be required of hospices reporting those services.

Summary of CMS Policy on the Utilization of G Codes in Home Health and Hospice

Medicare makes payment under the Home Health Prospective Payment System (HH PPS) on the basis of a national standardized 60-day episode payment rate that is adjusted for the applicable case-mix and wage index. The national standardized 60-day episode rate pays for the delivery of home health services, which includes the six home health disciplines (skilled nursing, home health aide, physical therapy, speech-language pathology, occupational therapy, and medical social services). G-Codes are used to differentiate between the six home health disciplines. Claims must report all home health services provided to the beneficiary within the episode. Each service must be reported in line item detail.

Frequently Asked Questions

What G-codes do we use to define skilled nursing services in home health and hospice settings?

Effective January 1, 2016, CMS established two additional G-codes to differentiate levels of nursing services provided during a hospice stay and a home health episode of care. These two G-codes and the retirement of G0154 are effective for hospice dates of service on and after January 1, 2016 and for home health episodes of care ending on or after January 1, 2016: Service is provided by an RN shall be coded as G0299, Service is provided by an LPN shall be coded as G0300.

  • G0154 Direct skilled services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes. – Retirement of G0154 will be effective on institutional claims for hospice dates of service on or after January 1, 2016 and for home health episodes of care ending on or after January 1, 2016.
  • G0299 Direct skilled services of a licensed nurse (RN) in the home health or hospice setting. - effective on institutional claims for hospice dates of service on or after January 1, 2016
  • G0300 Direct skilled services of a licensed nurse (LPN) in the home health or hospice setting – effective home health episodes of care ending on or after January 1, 2016

Effective January 1, 2011, CMS established additional G-Codes for the reporting of the skilled services of a licensed nurse in the management and evaluation of the care plan; another for the observation and assessment of a patient’s conditions when only the specialized skills of a licensed nurse can determine the patient’s status until the treatment regimen is essentially stabilized; and another for the reporting of the training or education of a patient, a patient’s family, or caregiver.

  • G0162 Skilled services by a licensed nurse (RN only) for management and evaluation of the plan of care, each 15 minutes (the patient’s underlying condition or complication requires an RN to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting).
  • G0163 Skilled services of a licensed nurse (LPN or RN) for the observation and assessment of the patient’s condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting).
  • G0164 Skilled services of a licensed nurse (LPN or RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes.

Can I use more than one G-Code per Visit?

HHAs must not report more than one G-code for the nursing visit regardless of the variety of nursing services provided during the visit.

CMS recognizes that, in the course of a visit, a nurse or qualified therapist could likely provide more than one of the nursing or therapy services reflected in the  and revised codes above. Similarly, the HHA must not report more than one G-code for the therapy visit, regardless of the variety of therapy services provided during the visit. In cases where more than one nursing or therapy service is provided in a visit, the HHA must report the G-code which reflects the service for which the clinician spent most of his/her time. For instance if direct skilled nursing services are provided, and the nurse also provides training/education of a patient or family member during that same visit, we would expect the HHA to report the G-code which reflects the service for which most of the time was spent during that visit. Similarly, if a qualified therapist is performing a therapy service and also establishes a maintenance program during the same visit, the HHA should report the G-code which reflects the service for which most of the time was spent during that visit.

What does the Medicare Benefit Policy Manual Chapter 7 have as outlined Skilled Therapy Services?

Section 40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy identifies that skilled therapy services must be reasonable and necessary to the treatment of the patient’s illness or injury or to the restoration or maintenance of function affected by the patient’s illness or injury. “It is necessary to determine whether individual therapy services are skilled and whether, in view of the patient’s overall condition, skilled management of the services provided is needed although many or all of the therapeutic services needed to treat the illness or injury do not require the skills of a therapist.” Chap 7, 40.2,1

What G-codes do we use to define physical therapy services in home health and hospice settings?

Effective January 1, 2011, use the following G-codes for the reporting of physical therapy, occupational, and speech-language therapy services provided by qualified therapists.

  • G0151 Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
  • G0152 Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
  • G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.

Effective January 1, 2011, CMS added additional G-codes (G0157 and G0158) for the reporting of physical therapy and occupational therapy services provided by qualified therapy assistants.

  • G0157 Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes.
  • G0158 Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes.

CMS also added and required the use of three additional G-codes for the reporting of the establishment or delivery of therapy maintenance programs by qualified therapists. The following are descriptions for those additional G-codes, for the reporting of the establishment or delivery of therapy maintenance programs by therapists:

  • G0159 Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes.
  • G0160 Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes.
  • G0161 Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes.

Can my qualified physical therapist open a case and then turn it over to an assistant?

Effective April 1, 2011, agencies can no longer have a qualified PT open a case and in effect turn it over to an assistant.  CMS believes it is paying for qualified therapy and expects to see the results of having the higher educated therapist actively involved with the patient’s care. This is one reason for the mandated qualified therapist to functionally assess the patient on the 13th and 19th therapy visit.

Helpful Tip


Your documentation must support the visit type and that visit type had best support the Plan of Care (POC). Visit notes will need to clearly justify the visit and show the value as it relates to the orders/goals of the POC. It will be easier for an auditor to see two or three recertifications of a chronic disease and pull out visits by type and ask specific questions and deny the visits. Remember, an episode doesn’t need to be fully denied, just having 5 of 14 visits denied could realize a $1000 episodic loss, depending on the patient HIPPS/HHRG

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OASIS-C1 Updates

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Hospice, OASIS, OASIS C1, OASIS-B, OASIS-C

OASIS Updates

OASIS-C1 is the current version of the OASIS data set.  It was developed from OASIS-C to accommodate the transition to the ICD-10 diagnosis coding system, as well as and other important stakeholder concerns such as updating clinical concepts, and revised item wording and response categories to improve item clarity.

 

OASIS-C1 Revisions for ICD-9 to ICD-10 Implimentation

The OASIS-C1 data item set was approved by the Office of Management and Budget (OMB) on February 6, 2014 and scheduled for implementation on October 1, 2014.  However, on April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which announced October 1, 2015 as the new compliance date.  Due to this delay, CMS had to ensure the collection and submission of OASIS data continued, until ICD-10 could be implemented.  Therefore, we have made interim changes to the OASIS-C1 data item set to allow use with ICD-9 until ICD-10 is adopted. .

Frequently Asked Questions

OASIS-C1/ICD-10 Revisions, effective October 1, 2015

OASIS-C1 / ICD-10 version:

  • TheOASIS-C1 / ICD-10 version of the OASIS data set replaces the five ICD-9-CM-based items in the OASIS-C1 / ICD-9 data set (M1010, M1016, M1020, M1022, M1024) with the corresponding ICD-10 items (M1011, M1017, M1021, M1023, M1025).   A table showing the differences between the OASIS-C1 / ICD-9 and OASIS-C1 / ICD-10 versions is available below in the Downloads section.
  • TheOASIS-C1 / ICD-10 version of the OASIS data set received Paperwork Reduction Act approval from OMB on May 29, 2015.
  • The OASIS-C1/ICD-10 data set is scheduled to be the version required for all assessments completed on or after October 1, 2015, when ICD-10 is scheduled to be implemented by CMS.
  • The complete set of OASIS-C1/ICD-10 data items, as well as the subsets of OASIS-C1/ICD-10 items that are to be collected at each time point (Start of Care, Recertification, etc.) can be found in the Downloads section below.
  • Detailed instructions for use of the OASIS-C1/ICD-10 data set can be found in OASIS-C1/ ICD-10 Guidance Manual, which is posted on the OASIS User Manuals page (see the link in the “Related Links” section below.)
  • If you have additional questions about completion of the OASIS-C1/ ICD-10 items, you can consult the OASIS Q&As using the "OASIS Q&As" link in the Related Links section below.
  • TheOASIS-C1 / ICD-10 version data must be encoded and submitted to CMS using the OASIS Data Specifications, version 2.12.n.  These can be accessed via the “OASIS Data Specifications” link in the “Related Links” section below.

OASIS-C1/ICD-9 Revisions, effective January 1, 2014

The delay of ICD-10 also impacted the implementation of OASIS C1 that had been scheduled for implementation October 1, 2014. OASIS C1 was delayed as five (5) of the data items require the use of ICD-10 codes. CMS published interim changes to the OASIS C1 data set. CMS modified OASIS C1 version to be implemented January 1, 2015, three months later than the original implementation date.

The new data set will be called “OASIS C1/ICD-9” hybrid version containing all the OASIS C1 changes that were approved in February, 2014, but the specific ICD-10 items will be replaced with their original ICD-9 coding item counterparts. That means that:

  • M1010 (inpatient diagnosis) will be in the hybrid version instead of M1011.
  • M1016 not M1017 will be present in the January, 2015 version.
  • M1020/M1022/M1024 will be back instead of the proposed M1021/M1023/M1025.

Starting January 1, 2015, OASIS assessment data will be submitted to CMS via the Assessment Submissions and Processing (ASAP) System, stated CMS.

The new OASIS C1/ICD-9 version is to be used on all assessments with a M0090 date on or after January 1, 2015.

OASIS-C1 / ICD-9 version:

  • A modified version of OASIS-C1 (referred to as “OASIS-C1/ ICD-9 version.”) was created. It  replaced the five OASIS-C1 items that use ICD-10 diagnosis codes (i.e. - M1011, M1017, M1021, M1023, M1025) with the corresponding ICD-9-CM based items from OASIS-C (i.e. – M1010, M1016, M1020, M1022, M1024).
  • TheOASIS-C1/ ICD-9 version underwent an “emergency” Paperwork Reduction Act review by OMB and was granted approval on October 10, 2014 for implementation on January 1, 2015.
  • The OASIS-C1/ICD-9 data set is required for all assessments completed on or after January 1, 2015 and until ICD-10 is implemented or until another disposition is made by CMS.
  • The complete set of OASIS-C1/ICD-9 data items, as well as the subsets of OASIS-C1/ICD-9 items that are to be collected at each time point (Start of Care, Recertification, etc.) can be found in the Downloads section below.
  • Detailed instructions for use of the OASIS-C1/ICD-9 data set can be found in OASIS-C1/ ICD-9 Guidance Manual, which is posted on the OASIS User Manuals page (see the link in the “Related Links” section below.)
  • If you have additional questions about completion of the OASIS-C1/ ICD-9 items, you can consult the OASIS Q&As using the "OASIS Q&As" link in the Related Links section below.
  • TheOASIS-C1 / ICD-9 version data must be encoded and submitted to CMS using OASIS Data Specifications, version 2.11.n.  These can be accessed via the “OASIS Data Specifications” link in the “Related Links” section below.

The Eight items Scheduled for Elimination

M1012 List each Inpatient Procedure and the associated ICD-9-CM procedure code relevant to the plan of care To be deleted at all time points

 

M1012 List each Inpatient Procedure and the associated ICD-9-CM procedure code relevant to the plan of care. To be deleted at all time points
M1310 Pressure Ulcer Length To be deleted at all time points
M1312 Pressure Ulcer Width To be deleted at all time points
M1314 Pressure Ulcer Length To be deleted at all time points
M1350 Does the Patient have a Skin Lesion or Open Wound To be deleted at Follow up FU and Discharge DC only
M1350 Does the Patient have a Skin Lesion or Open Wound To be deleted at Follow up FU and Discharge DC only
M1410 Respiratory Treatments To be deleted at Discharge DC
M2110 How often does the patient receive ADL or IADL assistance To be deleted at Discharge DC only

 

M2440 For what Reasons was the patient Admitted to a Nursing Home?: To be deleted at all time points

 

M1011 is a new M question that is expected to be collected for Case-Mix Adjustment purposes.

 

As of December, 2013, CMS states the number of questions per RFA type are as follows

 

RFA 1 SOC decrease from 95 to 91 questions
RFA 3 ROC decrease from 80 to 76 items
RFA 4 Recertification/FU remains the same with M1350 deleted but M1011 added
RFA 6 Transfer decrease from 19 to 18 questions
RFA 9 RFA 9 Discharge decrease from 61 to 55 items

Other Changes

Sequential order by item

M1700 The “e.g.” abbreviation was eliminated and replaced with “for example” to improve clarity in response “2”
M1730 “Validated” was added for clarity since both “standardized” and “validated” are specified in the OASIS guidance manual. Also added was the phrase “patient was screened” to response “2” for clarity and consistency
M1010 Inpatient diagnosis will be changed to item number M1011 Inpatient Diagnosis
M1012 DELETED
M1016 Diagnosis requiring medical or treatment regime change within 14 days will be changed to M1017 Diagnoses requiring medical or treatment regime change within 14 days
M1020 Primary Diagnosis changed to M1021
M1022 Other diagnoses changed to M1023 Other Diagnoses
M1024 Payment Diagnoses changed to M1023
M1032 Risk for hospitalization changed to M1033 Risk for hospitalization
M1334 “Response 0 – Newly Epithelialized” will be eliminated since this is an inappropriate option for this item (epithelialized stasis ulcers are not reported in OASIS)
M1040 Influenza vaccine changed to M1041 Influenza vaccine data collection period
M1045 Reason influenza vaccine not received changed to M1046 Influenza vaccine received
M1050 Pneumoncoccal vaccine changed to M1051 Pneumococcal vaccine
M1055 Reason PPV not received is changed to M1056 Reason PPV not received
M1308 Current number of unhealed non-epithelialized pressure ulcers at each stage is replaced by new item M1309 Worsening in pressure ulcer status since SOC/ROC. Column 2 is deleted
M1310, M1312, M1314 Pressure ulcer length, width, depth DELETED

 

M1310, M1312, M1314: M1340 New skip directions were needed due to deletion of M1350 at follow-up and discharge

 

M1310, M1312, M1314: M1340 M1350 Skin lesion or open wound DELETED at Recert and D/C

 

M1400 The “e.g.” abbreviation was eliminated and replaced with “for example” to increase clarity in responses “2” and “3”
M1410 Respiratory treatments DELETED at discharge
M1500 The wording in the item was revised to clarify that the ­reporting period includes the time of the assessment
M1510 Wording in item was revised to clarify that ­reporting period includes the time of the assessment; “e.g.” abbreviation eliminated and replaced with “for example” in responses “2” and “5”
M1610 The “i.e.” abbreviation was eliminated and replaced with “specifically” to improve clarity in response “2”
M1730 “Validated” was added for clarity since both “standardized” and “validated” are specified in the OASIS guidance manual. Also added was the phrase “patient was screened” to response “2” for clarity and consistency
M1740 : The “e.g.” abbreviation was eliminated and replaced with “for example” to improve clarity in response “4”
M1800 The “i.e.” abbreviation was eliminated and replaced with “specifically” to improve clarity in item stem
M1830 The phrase “throughout the bath” was deleted from ­the response “5” to include patients who need intermittent ­assistance bathing self in bed, at the sink, in a bedside chair, or on the commode
M1860 The “i.e.” abbreviation was eliminated and replaced with “specifically” to improve clarity in response “0”.  The “e.g.” ­abbreviation was eliminated and replaced with “for example” to improve clarity in response “1” and “2”
M1880  The “e.g.” abbreviation was eliminated and replaced with “for example” to improve clarity in the item stem. The “i.e.” ­abbreviation eliminated and replaced with “specifically” to improve clarity in response “0”

 

M1890 The “e.g.” abbreviation eliminated and replaced with “for example” to improve clarity in response “1”
M1900 To improve clarity, responses were modified so that all the relevant ADLs/IADLs are listed. The “i.e.” ­abbreviation was eliminated and replaced with “specifically,” and the “e.g.” ­abbreviation was eliminated and replaced with “for example” to improve clarity
M1910 Unnecessary wording was deleted. The words  “standardized, validated” have been added for ­consistency with the instructions in the OASIS-C guidance manual. The terms “no, low or minimal” have been added to reflect the fact that many falls risk assessment tools use these three terms to indicate low risk and congruency with terminology is more apparent.
M2000 The “i.e.” was replaced with “specifically,” and “e.g.” was replaced with “for example.  Wording was revised to reflect the OASIS guidance manual.  The term “adverse” was added to describe drug reactions while the term “significant” was added to describe side effects, and  “non-adherence” was added to non-compliance.
M2004 Wording in item and the NA response was revised to clarify that the reporting period includes the time of the ­assessment. The  “e.g.” abbreviation was eliminated and replaced with “for example” in responses “2” and “5”
M2015 Wording in the item as well as the NA response was revised to clarify that the reporting period includes the time of the ­assessment. The word “significant” was added to the item to ­describe side effects
M2040 The data collection period was clarified in the item. The term ­“ability ”was removed from the item title to be consistent with similar items
M2100 Types and sources of assistance changed to M2102 Types and sources of assistance. The Item title was simplified to “Types and Sources of ­Assistance”. Column headings were revised to ­clarify that “caregiver” refers to non-agency caregivers (such as family members, friends, or privately paid ­caregivers) and excludes care by agency staff; added text to ­column heading to clarify that “No assistance needed from Caregiver in this area” means that the patient is ­independent or does not have needs in this area.  Response options were simplified by combining “Caregiver(s) not likely to provide assistance” and “Caregiver(s) unwilling/unable to provide assistance”
M2110 Frequency of ADL or IADL assistance DELETED at discharge
M2250 Plan of Care synopsis: The “Not Applicable” responses were revised for rows “b,” “c,” “d,” “e,” “f,” and “g” to add detail, improve ­clarity, and be consistent with guidance in the OASIS-C ­manual. The line between “NA” and the text ­boxes were removed to i­mprove clarity
M2250:  M2300 Wording in item was ­revised to clarify that the reporting period includes the time of the ­assessment.  The word “status” was added to “holding/­observation” to bring the term into alignment with current instructions in the OASIS-C manual
M2250:  M2300: M2310 The wording in the item was changed to “seek and/or receive” to bring it into alignment with current instructions in OASIS-C manual. The response “1” was revised to include “adverse drug reactions” to being it into alignment with current instructions in the OASIS-C manual.
M2400 The wording in the item was revised to clarify that the ­reporting period includes the time of the assessment.  “Not Applicable” responses have been modified to add detail, improve clarity, and be consistent with responses in M2250 as well as the guidance in the OASIS-C manual. The line between “NA” and the text boxes was removed to improve clarity
M2430 The “e.g.” abbreviation was eliminated and replaced with “for example” to improve clarity in responses “3” and “5”

 

M2440 Reasons for nursing home admission DELETED

 

In total, unless additional changes are made, OASIS will move from 114 items to OASIS C1 with 110 items

OASIS C1 Revision, Hospice HIS Tool Implementation, effective July 1, 2014

HIS Data Elements

CMS believes the standardized data collection instrument will allow a more uniform patient-level data collection for quality reporting purposes. There are 51 data elements to be utilized on two HIS forms: Admission and Discharge. There are both administrative data elements as well as clinical process data elements. The latter includes:

  • Pain Screening and full Assessment
  • Dyspnea (SOB) Screening and Treatment
  • Medications (Opioids and Bowel Regimen)
  • Patient Preferences
  • Beliefs and Values

7 NQF endorsed quality measures

  • 1634 Pain Screening
  • 1637 Pain Assessment
  • 1639 Dyspnea Screening
  • 1638 Dyspnea Treatment
  • 1637 Patients treated with opioids and given a bowel regimen
  • 1641 Treatment Preferences
  • 1647 Beliefs/Values Addressed

OASIS C Revisions, effective 2010

OASIS-C refinements were focused on clinical assessment using standardized tools with subsequent processes chosen for intervention and care for the patient.

Risk assessment followed by specific process algorithms is a focus. With OASIS-C, CMS to included a way to measure an agency's use of evidenced based best practices. Since research supports the fact that best practices assist to prevent the exacerbation of serious conditions, then it is easy to see the CMS expectation that processes of care implemented according to evidenced based guidelines will ultimately lead to better clinical outcomes.

Diagnosis coding sections changes included M0230, M0240, and M0246 will be identified as M1020, M1022, and M1024. CMS is seeking an accurate portrait of the patient and their conditions. CMS eliminated the severity level identification and instead moved to listing other diagnoses "in the order to best reflect the seriousness of the patient's condition and justify the disciplines and services provided". The diagnoses should be sequenced by "the degree they impact the patient's health and need for home health care, rather than the degree of symptom control". Documentation is key.  Expert clinician/coders reviewing the record for proper coding will be vital. A point to note: Be very aware of coding hypertension, GERD documentation, Low vision documentation omissions, diabetes documentation and the correct coding choice, there are over 10, and personal histories of falls.

OASIS B Revisions, effective 2008

OASIS B refinements were focused on finance.

Helpful Tip


Visit CMS.gov "Home Health Quality Initiative" home page to learn more about home health quality goals.

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