On November 6, 2014, the Centers for Medicare & Medicaid Services (CMS) published the Final Rule for CY 2015 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; and Survey and Enforcement Requirements for Home Health Agencies. You can find the full text here. It can be a fun read for some but most, with better things to do in their lives, will find our condensed presentation below, which dives a little deeper into the final rule than this blog post, a whole a lot easier to digest.
The most exciting news, which everyone in the home health industry should be toasting to at their annual holiday parties, is that episodes beginning on or after January 1, 2015 are not subject to the 13th/19th visit reassessment rule. Our past blog post called this rule the most despised piece of regulation. The new requirement is for reassessments to be done at least every 30 days within a treatment cycle. This means that from the time of the evaluation to the time of the therapy discharge there must be a functional reassessment performed by a qualified therapist within a skilled visit at least every 30 days regardless of what episode you are in. Also, each therapy discipline has their own 30-day clock to follow. This means that calculation of specific visit time points between therapists of different disciplines will no longer be required. Keep in mind that the required content of the functional reassessment has not changed.
therapyBOSS, by the way, will intelligently track all reassessments for episodes begun prior to 1/1/2015 and only the 30-day one for episodes after. Complying with 30-days reassessments in therapyBOSS is a piece of cake thanks to the alerts which will tell you when therapists are about to hit reassessment checkpoints. Recertification evaluations in therapyBOSS are sufficiently comprehensive to qualify as functional reassessments, therefore reset the reassessment clock, and reassessment forms automatically populate with documented progress from visits performed.
The other big news is that the Face-to-Face (F2F) Encounter requirement has been changed. In response to the many comments received from the industry, CMS (they listen!) has done away with the narrative portion of the F2F form. For Start of Care (SOC) episodes that begin on or after January 1, 2015, home health agencies will be required to obtain the date of the qualifying encounter and the attestation statement from the physician confirming that the F2F encounter was performed within 90 days before or 30 days after the SOC timeframe and that the F2F encounter was related to the conditions that qualify the patient for home health. However, and this is important, it does not completely lessen the burden on HHAs – because if a chart is selected for review, the HHA will still be required to provide copies of the physician or acute/post-acute care facility’s medical record documentation that supports patient eligibility for the home health benefit including homebound status and medical condition. Also, if the patient is a management and evaluation RN case (G0162), the narrative will still be required to justify those types of visits.
Regarding physician or acute/post-acute care facility documentation, some commenters suggested that the home health agencies need to be allowed to request those records. CMS agreed that home health agencies would not be operating out of their limits to request copies of physician or acute/post-acute care facility medical records that document homebound status and reason for home health services. They also have provided monetary incentive for physicians to comply. If a home health agency episode of care is denied due to non-compliant Face-to-Face encounter documentation, the physician’s corresponding care plan oversight claim will be denied as well. It is not a significant amount of money but it is a start to a lot of beleaguered agencies who thrash against the wall of physician Face-to-Face non-compliance day after day.
The 2015 PPS final rule also tackled the issue of simplifying the qualification of Speech-Language Pathologists (SLPs) for home health care. In the final rule, after January 1, 2015 SLPs will qualify to provide home health services if they have a master’s or doctoral degree in speech-language pathology and are licensed as a SLP in the state where they are providing services. This is a change from the old rule that required SLPs to obtain a Certificate of Clinical Competence from the American Speech-Language-Hearing Association. For SLPs providing services in states or territories that do not have SLP licensure, there are specific minimum requirements set in the final rule. CMS stated that they decided to use the 2015 PPS final rule to clarify these requirements instead of waiting for the new Conditions of Participation because they understand that there is an immediate need for more qualified SLPs.
And what would a PPS Final Rule be without talking about money? Yes, the PPS rate is being adjusted again. This time, not only are the case-mix weights adjusting to average to zero but the case mix weights are changing in relation to each other. This means that some case mix weights are being adjusted more or less than others based on a complicated formula that takes into account claims and cost report data in an attempt to more accurately reflect the costs for each case mix value. The adjustments were completed in a budget-neutral manner so that there should be no great decrease in episode payments but it is difficult to determine what the final financial impact will be to agencies since there are so many more moving parts. However, one of the more significant changes for therapy companies is that CMS is increasing case-mix weights for lower therapy utilization and decreasing case-mix weights for high-therapy utilization in an attempt to remove the perceived bias in the system that makes a therapy home health referral more attractive to agencies than one without therapy.
There also seems to be an increased focus in encouraging agencies to review and improve quality metrics. From the 2% decrease in market basket increase amount for any agency not submitting quality data to “Pay-for-Reporting” to “Pay-for-Performance”, quality of care was addressed throughout the final rule. The rule explains “Pay-for-Reporting” as a minimum compliance rate of 70% “Quality Assessments Only” (QAO) for 2015. The percentage is figured by dividing the number of quality assessments by the total sum of quality and non-quality assessments. Page 66075 in the Final Rule explains quality assessments in detail. It appears that if agencies follow proper OASIS sequencing and ensure that all assessments are completed and transmitted properly, they will be in compliance with this part of the rule. CMS says they will review and report on compliance to the agencies before increasing the percentage of QAO in future PPS rules.
“Pay-for-Performance” is also referred to as value-based purchasing. It is an initiative by CMS to attempt to provide incentives to agencies for improving their quality of care. A program similar to this was tested in 2008-2010 but due to a lack of clarity regarding incentives and penalties and the length of time that it took to evaluate performance indicators, the program was not a great success. CMS is attempting this program again to begin in 2016. They propose a “greater upside benefit and downside risk” that will be clearly communicated to all agencies. Part of the proposal is between a 5%-8% increase or reduction in Medicare payments depending on agency performance relative to other agencies in the same geographic area with similar patient populations. Five to eight states will be selected to participate in the pilot program with 100% mandatory home health agency participation in those states. Commenters suggested some criteria for state selection; however final selection will be determined at a later date.
The delay in ICD-10 was addressed in the final rule as well. The Protecting Access to Medicare Act of 2014 delayed the implementation of ICD-10 until October 1, 2015. CMS has listed out the plan for ensuring agencies are prepared for this transition including educational articles, webinars, and comprehensive testing. The ICD-10-CM PPS Grouper is scheduled to be released April 1, 2015 to allow providers plenty of time to prepare. A draft version of the Grouper is scheduled to be posted to the website on or before January 1, 2015 so that vendors who have registered as beta-testers may begin to test it for issues and report on it before the April 1st posting. All providers should be ready to transmit ICD-10 OASIS and claims based on the M0090 Date Assessment Completed date on the OASIS.
The final rule also addressed medical necessity for patients whose primary reason for home health care was for insulin injection assistance. Table 34 in the Final Rule provides a list of diagnosis codes that support continued long-term insulin injection assistance. CMS notes that this table is not all-inclusive, however it supplies a good set of guidelines for home health agencies that may be unsure as to what conditions would support insulin injection assistance.
There was some continued discussion about advancing the Health Information Exchange (HIE). While CMS is encouraging usage of Electronic Health Records (EHR) for all provider types, home health agencies have not yet been given a hard date for compliance. There are some resources for providers curious about EHR information within the Final Rule as well.
Finally, the final rule spoke about Civil Monetary Penalties (CMPs) assessed to home health agencies when they have condition-level deficiencies identified in state surveys. The fines assessed range from $500 to $10,000 depending on the severity of the deficiency and instances of non-compliance. The final rule prohibits the ALJ from reducing monetary penalties assessed to a home health agency down to zero.
So that’s the 2015 Final Rule in a nutshell. As always, we here at Pragma-IT will continue to get you complete and accurate information as it becomes available.
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