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PPS Home Health Reform

PPS Home Health Reform. Revised CMS regulations By Renee Korb, President Korb Consulting, Inc. What we will Learn. Summary of payment changes What C – F & S stand for Formula’s & Calculations Strategies Billing and Technical Changes. Summary of Payment Changes.

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PPS Home Health Reform

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  1. PPS Home Health Reform Revised CMS regulations By Renee Korb, President Korb Consulting, Inc.

  2. What we will Learn • Summary of payment changes • What C – F & S stand for • Formula’s & Calculations • Strategies • Billing and Technical Changes

  3. Summary of Payment Changes • 80 episodes payment rates to 153 • Additional oasis questions effect payment score • New oasis questions • Early & Late episodes

  4. C = Clinical Domain Drivers • Diagnosis – not just primary • Clinical Condition

  5. F = Functional Components remain unchanged • Dressing – MO650 or MO660 • Bathing – MO670 • Toileting – MO680 • Transferring – MO690 • Ambulation – MO700

  6. Clinical & Functional 45 Clinical Oasis questions are assigned points based on the 4 Equation model 6 Functional Oasis questions are assigned points based on the 4 Equation model See Exhibit 1

  7. S = Service Utilization • OLD 10 therapy visit cut off

  8. S = Service Utilization NEW • 6 visits • 7 to 9 visits • 10 visits • 11 to 13 visits • 14 to 19 visits • 20 + visits

  9. The Calculation • 1st complete the Oasis • Identify if an early or late episode • Determine the number of therapy visits • Score clinical and functional items based on 4 equation model (Exhibit 1 – CMS Table 2A) • Assign CFS Severity levels based on scores (Exhibit 2 - CMS Table 3)

  10. The Calculation • National Rate X Case Mix Weight = Case Mix Rate • Identify Labor Portion (.77082 X Case Mix Rate) • Adjust for wage index (Labor Portion X Wage index for patients location) • Add Non Labor Portion to wage weighted labor portion • Calculate the NRS amount and add it on

  11. The Calculation an exampleAssumptions

  12. The Calculation an example

  13. Case Mix Groups • 153 Case Mix Groups (HHRGS) • Severity levels are: • C1 to C3 • F1 to F3 • S1 to S5 • Assigned to 5 Groups • Early Episode (1st & 2nd) Low Therapy (0 – 13 visits) • Early Episode (1st & 2nd) High Therapy (14 – 19 visits) • Late Episode (3+) Low Therapy (0 – 13 visits) • Late Episode (3+) High Therapy (14 – 19 visits) • All episodes 20+ therapy visits • Case weights range from .5827 to 3.4872

  14. Case Mix Scoring – CMS Table 3

  15. Clinical Scoring Domain ImpactCMS Table 4

  16. Functional Scoring Domain Impact

  17. Service Domain Scoring Impact

  18. EXAMPLES SERVICE DOMAIN IMPACT

  19. Table 9: Relative Weights for Non-routine Medical Supplies – Six-group Approach

  20. Other Changes SCIC (significant change in condition) Gone to the Wind

  21. Other Changes • The Outlier ratio has changed • Will result in fewer episodes that will qualify as an outlier

  22. Other Changes • LUPA Add On • Very 1st Episode or 1st in a series of adjacent episodes • $87.93 additional for the episode • Supposed to cover the additional cost of an initial assessment

  23. What’s Next?

  24. Calculate Agency Impact Understand and measure the financial impact to your prior episodes • List every episode • Attempt to get the following • DX • Visit totals by discipline • Episode dates • Episode payment • Patient name

  25. Calculate Agency Impact Measuring • Sort by client • Summarize between early and late episodes • Summarize early and late episodes by therapy utilization group • Apply industry estimates by category

  26. Sample Real World Analysis

  27. Analyze current case load • Review episodes • Sort episodes by DX codes • Sort by HHRG • Look for positive cases • Lower visits • Excellent outcomes • Reduced Hospitalizations • What can we learn from these

  28. Analyze your operations • Review your current operations and look for process changes that result in additional cost savings • Use Telehealth • Use the telephone • Look for disease management pathways or programs

  29. Analyze your operations • Staff training on OASIS for accuracy • Office or persons checking CWF to answer M0110 and re-check in 2-3 week timeframe • Coding for diagnosis very important, do any on line or audio courses available. Do not over use V codes

  30. Analyze your operations • Diagnosis sequencing extremely important. Refer to ICD-9 books for guidance • Consider making 1 person a coding expert • Use real time benchmarking systems to stay on top of outcomes and performance • Consider having an OASIS QA person to make sure all questions are answered consistently and accurately

  31. Analyze your operations • OASIS QA person to be sure intent is accurate for all SOC, Recerts and D/C. • Consider using HHA’s for rehab that do not require therapies • Check supplies to be sure you are using the most cost effective supply and not the most expensive

  32. Analyze your operations • Include all supplies on the bills and 485, even if they are supplies that are not being reimbursed. Be sure you know supply costs, Look at best practice for wound care

  33. Analyze your operations • Billable Medical Supply List Exhibit A • Get your medical supply billing process in place (Payment rates in CMS Table 9)

  34. Plan for Cash Flow Interruptions • Will the Intermediaries be ready?? • Will your vendors be ready? • Will your staff be trained?

  35. Back Office Changes • New methodology requires tracking new things • Which episode is it • Accurately project therapy visits • Identify supplies or why no supplies

  36. Back Office Changes • New methodology requires clinical reporting changes • New Oasis • During transition will file both forms for episodes under old rules and episodes under new rules

  37. Back Office Changes • New methodology requires billing changes • Results in IT interface changes

  38. Technical Process Changes CR 5746 (Exhibit B) contains revisions to a number of sections for case mix policy changes • Revises field by field billing instructions • Describes the new coding required • Contains detailed description of new HH pricer Logic • Contains IT requirements for Medicare ET

  39. Data Submission Changes • Elimination of SCIC • Effective episodes starting on or after 1/1/08 • Claims must NOT contain more than 1 revenue code 0023 line • Claims will be rejected and returned

  40. Data Submission Changes • New HIPPS coding structure requires additional information to determine payment • Many new HIPPS codes

  41. Data Submission Changes Need episode sequence and grouping step • New HIPPS codes will begin with a number to represent the episode sequence and therapy visit grouping 1 = early episodes and 0 – 13 therapy visits 2 = early episodes and 14 – 19 therapy visits 3 = later episodes and 0 – 13 therapy visits 4 = later episodes and 14 – 19 therapy visits 5 = all episodes and 20+ therapy visits

  42. Data Submission Changes • Positions 2, 3 & 4 continue to report severity levels C F & S Domains • Clinical domain reported with letters A, B or C • Functional domain letters reported with F, G or H • Service domain reported with letters K,L, M, N & P

  43. Data Submission Changes Need non-routine supply severity level • Position 5 of the code will represent NRS S – Level 1 NRS provided T – Level 2 NRS provided U – Level 3 NRS provided V – Level 4 NRS provided W – Level 5 NRS provided X– Level 6 NRS provided

  44. Data Submission Changes Need non-routine supply severity level • Position 5 of the code will represent NRS 1 – Level 1 NRS NOT provided 2 – Level 2 NRS NOT provided 3 – Level 3 NRS NOT provided 4 – Level 4 NRS NOT provided 5 – Level 5 NRS NOT provided 6– Level 6 NRS NOT provided

  45. Data Submission Changes New format for treatment authorization code • The “Claims Oasis Matching Key” contains information needed • The last 9 positions will carry recoding info • 1 number to show the episode sequence (1 =early, 2 = late)

  46. Data Submission Changes • 4 pairs of letters that encode the scores in the clinical and functional domains as calculated under each of the 4 equations of the refined case mix model • Again, “possible new format” matches CR 5746 • Format will be validated by Medicare systems

  47. Intermediaries Re-code Claims • Medicare systems will validate your final claim • Did the original episode get reported with the correct sequence # (early or late) • Are the therapy levels reported supported by actual covered therapy visits

  48. Intermediaries Re-code Claims • Errors found in sequence and therapy reporting will automatically adjust the codes and pay accordingly • Values in the treatment authorization code will be used to make the determination

  49. Supply Reporting • CMS is creating a validation process • Ensure that the 5th position of the HIPPS code is a letter indicating supplies were reported • At least 1 revenue code 27x or 623 line must be present on the claim

  50. Supply Reporting • A Grace period will initially allow for absent supply lines • Claim will be paid • Message on the Remittance advice will alert HHA to the inconsistent data • After the “Grace Period” claims will be rejected

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