Home Health & Hospice

2013 Home Health Prospective Payment System (PPS) Final Rule Released

Homecare Insider, November 5, 2012

The Centers for Medicare and Medicaid Services (CMS) issued its annual Home Health Prospective Payment System (HH PPS) Final Rule last Friday, November 2, which will update the HH PPS rates for 2013.

Payment changes

The final rule estimates a change in payment that will vary among providers, which includes the net effect of a 1.3 percent payment update, the wage index update, an update to the fixed-dollar loss (FDL) ratio, and the case-mix coding adjustment.

According to the official CMS press release, the Patient Protection and Affordable Care Act (ACA) applies a 1-percentage point reduction to the 2013 home health market basket. As the 2013 market basket is equal to 2.3%, the episode payment update for homecare agencies in 2013 will be 1.32%. The final rule also rebases and revises the home health market basket. This rebasing should not be a surprise to homecare providers as it was in the proposed rule that was issued in July.

The low utilization payment adjustment rates for agencies that submit quality data were also updated and for those agencies that do not report quality data, reimbursement will continue to be reduced by 2 percent.

In addition to these payment updates, there has been a significant clarification in the coding rules. Citing Attachment D, CMS has clarified the only codes not allowed in homecare are acute fractures. Therefore, these will be the only codes allowed in M1024 as resolved, and therefore can accumulate case-mix points. Any other resolved condition, such as neoplasms, diabetes codes, neuro codes and skin, will no longer garner case-mix points if placed in M1024. CMS further clarified, that if the agency wishes, they can continue to place these in M1024 to paint a clearer picture of the patient status, but these would not accumulate case-mix points.

Face-to-face encounter flexibility

The final rule has implemented its proposal, which was featured in the proposed rule in regards to the face-to-face encounter. Now for patients admitted to home health from an acute or post-acute facility, it is allowed for an NPP in an acute or post-acute facility to perform the face-to-face encounter in collaboration with or under the supervision of the physician who has privileges and cared for the patient in the acute or post-acute facility, and allow such physician to inform the certifying physician of the patient’s homebound status and need for skilled services.

Changes to therapy

Current home health regulations state that in cases where the patient is receiving more than one type of therapy, the qualified therapist from each discipline must provide all of the therapy, and functionally reassess the patient during the visit associated with that discipline that is scheduled to occur close to the 14th Medicare-covered therapy visit, but no later than the 13th Medicare-covered therapy visit and a qualified therapist from each discipline must provide all of the therapy and functionally reassess the patient during the visit associated with that discipline that is scheduled to occur close to the 20th Medicare-covered therapy visit, but no later than the 19th Medicare-covered therapy visit.

In the final rule, CMS states that because they received numerous inquiries from the home health industry on what CMS considered “close to,” they decided there needed to be more precise guidance.

CMS has finalized their proposal to revise these regulations. Going forward in cases where the patient is receiving more than one type of therapy, qualified therapists must complete their reassessment visits during the 11th, 12 th, or 13th visit for the required 13th visit reassessment and the 17th, 18th, or 19th visit for the required 19th visit reassessment.

They are also modifying the regulation text to state that in instances where patients receive more than one type of therapy, if the frequency of a particular discipline, as ordered by a physician, does not make it feasible for the reassessment to occur during the specified timeframes without providing an extra unnecessary visit or delaying a visit, then it will still be acceptable for the qualified therapist from each discipline to provide all of the therapy and functionally reassess the patient during the visit associated with that discipline that is scheduled to occur closest to the 14th Medicare-covered therapy visit, but no later than the 13th Medicare-covered therapy visit. Also, a qualified therapist from each discipline must provide all of the therapy and functionally reassess the patient during the visit associated with that discipline that is scheduled to occur closest to the 20th Medicare-covered therapy visit, but no later than the 19th Medicare-covered therapy visit.

The rule also clarifies that if an assessment is missed by a discipline, and performed after the 13th and 19th visit, then the agency will continue to bill the disciplines that did complete the assessments timely. The discipline that violated the assessment rule can then charge from the date of the reassessment. Currently, an agency cannot bill for the reassessment visit, but the visit following

Survey modifications and home health sanctions

The final rule has cemented the fact that there will now be additional enforceable actions for home health agencies with deficiencies, including alternative sanctions.

Sanctions include:

  • Termination of a HHA provider agreement if that HHA is not in substantial compliance with the Medicare requirements (that is, the failure to meet one or more conditions of participation is considered a lack of substantial compliance).
  • Termination of an HHA that fails to correct its deficiencies within a reasonable time (ordinarily no more than 60 days), even if those deficiencies are at the standard rather than at a condition level.
  • Monetary sanctions for conditional level deficiencies and standard level deficiencies if they are the same as a previous conditional level.
  • Temporary management assigned by CMS contractors to place in the agency to provide oversight and attempt to bring the agency into compliance.

CMS stated sanctions would only be applied in the event of conditional level deficiencies. However, if an agency has a standard level deficiency from a repeat level conditional level, then sanctions could be implemented. CMS will also withhold the application of civil monetary penalties, payment suspension, and the IDR process (Informal Dispute Resolution) until July 1, 2014.

Hospice QAPI
 
The final rule stated that hospices must participate in a QAPI program that includes at least three quality indicators related to patient care. Hospices are not required to report their level of performance on these patient care related indicators, but rather be used by CMS to ascertain the breadth and content of existing hospice QAPI programs.  
 For 2015 and beyond, hospices will report the following:
  • Pain management
  • Structural measurement of an active QAPI program. CMS intent is to develop an item set that would collect data elements that are already part of hospice practice and could be used to calculate the NQF endorsed QMs for hospice. The following data items that will support the endorsed measures include:
    • Patients treated with opioids who are given a bowel regimen.
    • Pain screening.
    • Pain assessment.
    • Dyspnea treatment.
    • Dyspnea screening. CMS envisions that these measures are possible measures.

Click here to access the final rule.

Editor’s Note: Look for more news and analysis on this final rule in the coming weeks from Beacon Health.