2018 Home Health PPS Final Rule

CMS has released the Home Health PPS Final Rule for 2018. The good news is that there are not a lot of regulatory changes that home health agencies have to immediately prepare for. With Emergency Preparedness and Conditions of Participation, it appears CMS has given agencies a procedural reprieve with this update. However, there are some major changes being proposed for 2019.

Changes for 2018

Agencies can anticipate about a 0.4 percent reduction in episode payments. In addition, the three percent rural add-on has been discontinued for episodes that end on or after January 1, 2018.

There were changes made to the four-equation home health groupings model (HHGM) using claims data in CY 2016. The recalibration resulted in 8 variables added, 12 variables dropped, 14 variables increased, 48 variables decreased and 50 variables stayed the same.

Home Health Value Based Purchasing (HHVBP)

Home Health Value Based Purchasing (HHVBP) is going to change in a few ways in the states impacted by that payment model. The maximum payment adjustment based on performance will be 3 percent in CY 2018. HH CAHPS threshold will change from 20 completed surveys to 40 completed surveys in the year. If less than 40 are completed, HH CAHPS scores will be removed from consideration for HHVBP payment or penalty. The thresholds for OASIS-based and claims-based measures will stay at 20 reportable episodes per year.

Drug Education on All Medications Provided to Patient/Caregiver during All Episodes of Care is going to be removed from HHVBP due to providers reaching full performance on this measure. There are several composite measures that are under consideration for future rule-making including “Total Change in ADL/IADL Performance”, “Composite Functional Decline”, and “Behavioral Health Measures”.

Home Health Quality Reporting Program

Changes are coming to the Home Health Care Quality Reporting Program (HH QRP) as well. As part of complying with the IMPACT Act of 2014, CMS is moving to standardize post-acute care assessment data across HHAs, LTCHs, IRFs, and SNFs to be able to compare responses for patients transferred from one facility type to another.

Proposed additions to HH QRP for CY 2020 are “Percent of Residents Experiencing One or More Falls with Major Injury” and “Percent of Long-Term Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function”. The current pressure ulcer measure “Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened” will be modified to “Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury”. Data collection for these measures would begin January 1, 2019.

They are also considering questions related to social risk factors for patients in order to assure all beneficiaries have adequate access to high quality care. However, after the initial trial period, NQF extended the analysis phase of the project for an additional three years.

A New OASIS Data Set

The 2018 Final Rule includes a new OASIS data set effective January 1, 2019. This set would result in:

• A net reduction of 38 data elements from the OASIS Start of Care – 70 removed and 32 added
• A net reduction of 38 data elements from the OASIS Resumption of Care – 70 removed and 32 added
• A net reduction of 2 data elements from the OASIS Recertification/Follow-Up – 18 removed and 16 added
• A net reduction of 38 data elements from the OASIS Transfer to Inpatient Facility – 42 removed and 4 added
• A net addition of 3 data elements from the OASIS Death at Home – 1 removed and 4 added
• A net reduction of 9 data elements from the OASIS Discharge from Agency – 40 removed and 31 added

You can see the proposed new OASIS items here and a table summarizing the changes here. In the final rule, CMS stated they would not be including the new OASIS items associated with Cognitive Function and Mental Status; Special Services, Treatments, and Interventions; and Impairments. When there are any finalized changes to the OASIS set, you can count on therapyBOSS to be prepared to implement those changes seamlessly for your clinical staff.

Home Health Groupings Model (HHGM) on hold

Part of the proposed rule was a plan to change the payment methodology from a 60-day period to a 30-day period. CMS has put this plan on hold but it is still under consideration for the future so it is included in this article for informational purposes only. Essentially, patient care episodes will still be 60-days long. Billing periods will go from 60-days to 30-days so that each care episode will potentially have two billing periods. CMS is proposing that since the billing episodes are of shorter duration, they may eliminate RAP payments and pay the full value on the final claim. They have provided several tools agencies may use to estimate the impact of HHGM on cash flow. See the final rule for more details.

There are also proposed changes to the home health groupings model (HHGM) where number of therapy visits would no longer be a factor in the grouper equation. This new method would take into account four components:

1. Whether the episode is early or late:
   1. “Early” would be re-defined to mean the first of any sequential 30-day billing period where there was no end of billing period in the prior 60-days
   2. “Late” would be all other episodes
2. What the admission source category is reflected in M1000 of the OASIS:
   1. “Institutional” is a new admission/billing period for a patient from an acute/post-acute facility (inpatient acute care hospitals, skilled nursing facilities, inpatient rehab facilities, or long-term hospitals) within 14 days of the billing period
   2. “Institutional” is also any billing period where the patient had an acute care hospital stay during the prior 30-day billing period – this does not include post-acute care stays since Medicare expects agencies to discharge and readmit in these cases
   3. “Community” is all other admissions/billing periods
3. Which of six clinical groups the patient’s principle diagnosis fits into with the potential of a comorbidity adjustment for certain secondary diagnoses. Proposed clinical groupings can be found here HHGM Grouping Tool by downloading the HHGM Grouping Tool.zip file and opening Grouping Tool – ICD10 DXs.csv. The groupings are:
   1. Musculoskeletal Rehabilitation (MS)
   2. Neuro/Stroke Rehabilitation (NEURO)
   3. Wounds – Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care (WOUND)
   4. Behavioral Health Care (BH)
   5. Complex Nursing Interventions (COMPLEX)
   6. Medication Management, Teaching and Assessment (MMTA)
   7. Questionable Encounter (QE) – this would be a catch-all for vague codes or codes inappropriate for homecare and claims with these diagnoses would be returned to provider for recoding
4. Additionally, the patient functional OASIS scores will be taken into consideration – as reflected in OASIS M1800, M1810, M1820, M1830, M1840, M1850, M1860, and M1033.

This reconfiguration was met with a lot of opposition in the industry because of the potential negative economic impact to agencies. While HHGM has been put on hold, we can anticipate that HHGM will not be going away any time soon.