2015 home health medicare payment ... 1 2015 home health medicare payment & regulatory updates...
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2/27/2015
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2015 HOME HEALTH MEDICARE PAYMENT & REGULATORY UPDATES – PART III
Billing & Physician Face-to-Face Encounters
February 26, 20152:00 p.m. – 3:00 p.m. CT
M. Aaron Little, CPAManaging Director
mlittle@bkd.com
2/27/2015
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• Participate in entire webinar• Answer polls when they are provided• If you are viewing this webinar in a group Complete group attendance form with
• Title & date of live webinar• Your company name• Your printed name, signature & email address
All group attendance sheets must be submitted to within 24 hours of live webinar
Answer polls when they are provided
• If all eligibility requirements are met, each participant will be emailed their CPE certificates within 15 business days of live webinar
TO RECEIVE CPE CREDIT
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4OBJECTIVES
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• 2015 changes to Medicare home health (HH) Payment rates Core-based statistical area (CBSA) code changes Prospective payment system (PPS) model changes Therapy reassessments Physician face-to-face (FTF) encounter changes
• Payment validation tools
TODAY’S OBJECTIVES
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62015 FINAL PAYMENT RULE
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• Medicare HH PPS final payment rule for 2015 Federal Register dated November 6, 2014
• http://www.gpo.gov/fdsys/pkg/FR-2014-11-06/pdf/2014-26057.pdf
Payment rate changes effective for episodes ending on & after January 1, 2015
2015 FINAL RULE
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Federal Register dated December 2, 2014• http://www.gpo.gov/fdsys/pkg/FR-2014-12-
02/pdf/2014-28396.pdf• Correction notice clarifying new therapy reassessment
requirements effective for episodes beginning January 1, 2015
Change Request 8969 dated December 9, 2014• http://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/Downloads/R3145CP.pdf
• Summarizes rate changes
2015 FINAL RULE
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9PAYMENT RATE CHANGES
• All rate changes effective for episodes endingon & after January 1, 2015 2% sequestration reduction still applicable
• New national standard episode payment rates $2,961.38 urban rate $3,050.22 rural rate
• 3% rural add-on still applicable
PAYMENT RATE CHANGES
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• No changes to situations that result in penalties of 2% reduction in payment rates Nonsubmission of Outcome & Assessment
Information Set (OASIS) data Nonsubmission of HH Consumer Assessment of
Healthcare Providers (CAHPS) data
PAYMENT RATE CHANGES
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• No changes to labor or nonlabor ratios 0.78535 labor ratio 0.21465 nonlabor ratio
• No changes to outlier ratios 0.45 fixed dollar loss ratio 0.80 loss sharing ratio
PAYMENT RATE CHANGES
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• New low utilization payment adjustment (LUPA) per-visit rates
PAYMENT RATE CHANGES
Discipline Urban* Rural*
Skilled nursing (SN) $ 127.83 $ 131.66
Physical therapy (PT) 139.75 143.94
Occupational therapy 140.70 144.92
Speech-language pathology (SLP) 151.88 156.44
Medical social services 204.91 211.06
Home health aide 57.89 59.63
*All rates subject to wage-index adjustment
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• No changes to LUPA payment add-on ratios 1.8451 SN ratio 1.6700 PT ratio 1.6266 SLP ratio
PAYMENT RATE CHANGES
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New nonroutine medical supply (NRS) payment add-on rates
PAYMENT RATE CHANGES
NRS Severity Level(HIPPS Code Character) Urban Rural
Level 1 (S or 1) $ 14.36 $ 14.79
Level 2 (T or 2) 51.86 53.42
Level 3 (U or 3) 142.19 146.46
Level 4 (V or 4) 211.25 217.60
Level 5 (W or 5) 325.76 335.55
Level 6 (X or 6) 560.27 577.11
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16CBSA CODE CHANGES
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• Transition year for many counties From urban to rural, rural to urban or between urban
or rural areas Effective for episodes ended on & after January 1,
2015• New temporary billing codes to be used for all
transition counties Codes begin with “5”
• Episodes began in 2014 & ended in 2015 may require different CBSA code billed on final claim than request for anticipated payment (RAP)
CBSA CODE CHANGES
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• Transition counties paid blended wage-index adjustment 50% of wage-index adjustment from both current
& prior classification
• Critical to identify billing codes for all counties Billing edits do not prevent incorrect CBSA codes
from being billed & paid
CBSA CODE CHANGES
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• Example 1 Washington County, Missouri
• Classified in CBSA “41180 St. Louis, MO” in 2014• Classified in CBSA “99926 Rural Missouri” in 2015• Billed with transition code “50090” in 2015
Paid blended wage-index adjustment of 0.8546• Episodes beginning in 2014 & ending in 2015
RAP billed with 41180 Final claim billed with 50090
• Paid rural national standard rate Including 3% rural add-on
CBSA CODE CHANGES
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• Example 2 Scott County, Indiana
• Classified in CBSA “99915 Rural Indiana” in 2014• Classified in CBSA “31140 Louisville, KY-Jefferson
County, IN” in 2015• Billed with transition code “50040” in 2015
Paid blended wage-index adjustment of 0.8511• Episodes beginning in 2014 & ending in 2015
RAP billed with 99915 Final claim billed with 50040
• Paid urban national standard rate
CBSA CODE CHANGES
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• Example 3 Marin County, California
• Classified in CBSA “41884 San Francisco, CA” in 2014• Classified in CBSA “42034 San Rafael, CA” in 2015• Billed with new CBSA code “42034” in 2015
Paid wage-index adjustment 1.7260
• Episodes beginning in 2014 & ending in 2015 RAP billed with 41884 Final claim billed with 42034
• Paid urban national standard rate
CBSA CODE CHANGES
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• HH PPS payment rate tables available on bkd.com for all CBSAs Requires following information
• Name• Organization• Email address• Rate year• CBSA code
PPS RATE TABLES
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23PPS MODEL CHANGES
• Severity scores• Grouper• Case-mix weights
PPS MODEL CHANGES
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• Severity scores New severity scoring methodology
• Patient characteristics coded on OASIS that have PPS payment value, i.e., severity scores Four different equations for calculating severity scores
• Grouped into Home Health Resource Groups (HHRGs) HHRGs are translated into HIPPS codes & matched to case-mix
weights
Applies to episodes beginning in 2015
PPS MODEL CHANGES
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Patient characteristics coded on OASIS that generate severity scores & determine case-mix weight
• Episode timing• Clinical dimension
14 OASIS questions 45 scoring variables
• Functional dimension Seven OASIS questions Six scoring variables
• Service dimension Estimated number of therapy visits
PPS MODEL CHANGES
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PPS MODEL CHANGES
Patient Characteristic Severity Points
Coded on OASIS Equation 1 Equation 2 Equation 3 Equation 4
2014 Severity Scoring Variables
M1020 Primary diagnosis = diabetes 5 13 1 8
M1342 Surgical wound status = “2 Early/partial granulation” 0 2 3 0
2015 Severity Scoring Variables
M1020 Primary diagnosis = diabetes 0 8 0 7
M1342 Surgical wound status = “2 Early/partial granulation” 1 7 6 14
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• Grouper Substantial changes in 2015 to PPS grouper
• Model for grouping severity scores into severity levels Clinical dimension severity level Functional dimension severity level Service dimension severity level
Applies to episodes ending in 2015
PPS MODEL CHANGES
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2015 Payment Grouping
Severity LevelHIPPSValue
1(Early)
2(Early)
3(Late)
4(Late)
5(Early or
Late)
Clinical Dimension Severity Points
C1 LowC2 ModerateC3 High
ABC
0 to 12 to 3
4+
0 to 12 to 7
8+
01
2+
0 to 56 to 12
13+
0 to 34 to 16
17+
Functional Dimension Severity Points
F1 LowF2 ModerateF3 High
FGH
0 to 1415
16+
0 to 34 to 13
14+
0 to 910
11+
01 to 7
8+
0 to 23 to 5
6+
Service Utilization Dimension Therapy Visits
S1S2S3S4S5
KLMNP
0 to 56
7 to 910
11 to 13
14 to 1516 to 1718 to 19
NoneNone
0 to 56
7 to 910
11 to 13
14 to 1516 to 1718 to 19
NoneNone
20+NoneNoneNoneNone
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2014 Payment Grouping
Severity LevelHIPPSValue
1(Early)
2(Early)
3(Late)
4(Late)
5(Early or
Late)
Clinical Dimension Severity Points
C1 LowC2 ModerateC3 High
ABC
0 to 45 to 8
9+
0 to 67 to 14
15+
0 to 23 to 5
6+
0 to 89 to 16
17+
0 to 78 to 14
15+
Functional Dimension Severity Points
F1 LowF2 ModerateF3 High
FGH
0 to 56
7+
0 to 67
8+
0 to 89
10+
0 to 78
9+
0 to 67
8+
Service Utilization Dimension Therapy Visits
S1S2S3S4S5
KLMNP
0 to 56
7 to 910
11 to 13
14 to 1516 to 1718 to 19
NoneNone
0 to 56
7 to 910
11 to 13
14 to 1516 to 1718 to 19
NoneNone
20+NoneNoneNoneNone
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• Case-mix weights Substantial changes in 2015 to case-mix weights
• Ratio determined by OASIS assessment that determines episode payment Severity points are grouped into severity levels which are
matched to case-mix weights• All case-mix weights changed in 2015
Health Insurance PPS (HIPPS) codes unchanged• 0.4942 low• 2.2950 high
Applies to episodes ending in 2015
PPS MODEL CHANGES
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PPS MODEL CHANGES
HIPPSCode
HHRGCode
EpisodeTiming
TherapyUtilization
Range
2015Case-mixWeight
2014Case-mixWeight
1AFKS C1F1S1 Early 0 0.5985 0.6080
3AFKS C1F1S1 Late 0 0.4942 0.4970
2AFKS C1F1S1 Early 14 to 15 1.2270 1.2049
4AFKS C1F1S1 Late 14 to 15 1.2407 1.2494
5AFKS C1F1S1 Early or late 20+ 1.8122 1.6745
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Source: CGS
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• Example 1 Episode beginning in 2014 & ending in 2015
• RAP billed with HIPPS code “1AGPT” Paid based on case-mix weight 1.1738
• Early episode• Estimated 11 to 13 therapy visits
• Final claim paid with HIPPS code “1AGPT” Paid based on case-mix weight 1.1581
• Medicare Common Working File (CWF) confirmed episode status as early
• Billed 11 to 13 therapy visits on final claim
PPS MODEL CHANGES
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• Example 2 Episode beginning in 2014 & ending in 2015
• RAP billed with HIPPS code “1AGPT” Paid based on case-mix weight 1.1738
• Early episode• Estimated 11 to 13 therapy visits• “AFCHEICH” last eight characters of OASIS matching string
PPS MODEL CHANGES
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2014 Payment Grouping
Severity LevelHIPPSValue
1(Early)
2(Early)
3(Late)
4(Late)
5(Early or
Late)
Clinical Dimension Severity Points
C1 LowC2 ModerateC3 High
ABC
0 to 45 to 8
9+
0 to 67 to 14
15+
0 to 23 to 5
6+
0 to 89 to 16
17+
0 to 78 to 14
15+
Functional Dimension Severity Points
F1 LowF2 ModerateF3 High
FGH
0 to 56
7+
0 to 67
8+
0 to 89
10+
0 to 78
9+
0 to 67
8+
Service Utilization Dimension Therapy Visits
S1S2S3S4S5
KLMNP
0 to 56
7 to 910
11 to 13
14 to 1516 to 1718 to 19
NoneNone
0 to 56
7 to 910
11 to 13
14 to 1516 to 1718 to 19
NoneNone
20+NoneNoneNoneNone
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• Example 2• Final claim paid with HIPPS code “4AHKT”
Paid based on case-mix weight 1.3730• Medicare CWF confirmed episode status as late• Billed 15 therapy visits on final claim• “AFCHEICH” last eight characters of OASIS matching string
Late episodes with 14 or more therapy visits falls into payment grouping “4”
“CH” indicating clinical & functional scores for payment grouping “4”• “C” = three clinical severity points• “H” = eight functional severity points
PPS MODEL CHANGES
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2015 Payment Grouping
Severity LevelHIPPSValue
1(Early)
2(Early)
3(Late)
4(Late)
5(Early or
Late)
Clinical Dimension Severity Points
C1 LowC2 ModerateC3 High
ABC
0 to 12 to 3
4+
0 to 12 to 7
8+
01
2+
0 to 56 to 12
13+
0 to 34 to 16
17+
Functional Dimension Severity Points
F1 LowF2 ModerateF3 High
FGH
0 to 1415
16+
0 to 34 to 13
14+
0 to 910
11+
01 to 7
8+
0 to 23 to 5
6+
Service Utilization Dimension Therapy Visits
S1S2S3S4S5
KLMNP
0 to 56
7 to 910
11 to 13
14 to 1516 to 1718 to 19
NoneNone
0 to 56
7 to 910
11 to 13
14 to 1516 to 1718 to 19
NoneNone
20+NoneNoneNoneNone
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39THERAPY REASSESSMENTS
• Therapy reassessments now required only at least every 30 calendar days Effective for episodes beginning January 1, 2015 Applies to each therapy discipline involved
• PT, OT & SLP
30 days reset each time a reassessment occurs Must be performed by qualified therapist
• Assistant visits do not qualify
No longer required prior to 14th & 19th visit
THERAPY REASSESSMENTS
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Must be performed using objective measurement in accordance with professional standards of clinical practice
Must enable comparison of successive measurements to determine effectiveness of therapy goals
Must document measurement results & effectiveness See archived BKD webinar 2015 Home Health
Medicare Payment & Regulatory Updates – Part II from February 17, 2015
THERAPY REASSESSMENTS
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Example 1
THERAPY REASSESSMENTS
Description HCPCS Date
PT evaluation G0151 01/01/15
PT assistant G0157 01/03/15
PT assistant G0157 01/05/15
PT assistant G0157 01/07/15
PT assistant G0157 01/09/15
PT assistant G0157 01/11/15
PT assistant G0157 01/13/15
PT assistant G0157 01/15/15
PT assistant G0157 01/17/15
Description HCPCS Date
PT assistant G0157 01/19/15
PT assistant G0157 01/21/15
PT assistant G0157 01/23/15
PT assistant G0157 01/25/15
PT assistant G0157 01/27/15
PT reassessment G0151 01/29/15
PT assistant G0157 01/31/15
PT assistant G0157 02/02/15
PT discharge G0151 02/04/15
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Example 2
THERAPY REASSESSMENTS
Description HCPCS Date
PT evaluation G0151 01/01/15
OT evaluation G0152 01/03/15
PT assistant G0157 01/05/15
OT assistant G0158 01/07/15
PT reassessment G0151 01/09/15
OT assistant G0158 01/11/15
PT assistant G0157 01/13/15
OT assistant G0158 01/15/15
PT assistant G0157 01/17/15
Description HCPCS Date
OT assistant G0158 01/19/15
PT assistant G0157 01/21/15
OT assistant G0158 01/28/15
PT assistant G0157 01/31/15
OT reassessment G0152 02/02/15
PT reassessment G0151 02/06/15
PT assistant G0157 02/08/15
PT assistant G0157 02/10/15
PT discharge G0151 02/14/15
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44PHYSICIAN FTF ENCOUNTERS
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• Effective for episodes beginning on & after January 1, 2015 Physician narrative no longer required on FTF
certification However, documentation in physician’s medical
records must justify referral for Medicare HH services• Must support need for skilled services & homebound status
MLN Matters SE1436• http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNMattersArticles/downloads/SE1436.pdf
PHYSICIAN FTF ENCOUNTERS
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• Physician FTF encounter certification form Document still required to be signed by physician
prior to claim being billed• Form still needs to include
Date of encounter Indication that encounter was related to primary reason
patient requires HH• Does not need to list specific diagnosis codes
Indication encounter was performed by allowed physician or NPP
Certification that patient is homebound & in need of skilled services
PHYSICIAN FTF ENCOUNTERS
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• Supporting documentation Certifying physician &/or inpatient physician
medical records shall be used as basis for certification of HH eligibility• Must be sufficient to justify referral to HH &
demonstrate need for skilled services & homebound status Must include actual clinical note used to document FTF
encounter & must indicate encounter• Occurred within required timeframe• Related to primary reason patient requires HH• Was performed by allowed physician or NPP
PHYSICIAN FTF ENCOUNTERS
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Information from HH offering additional support for skilled need & homebound status can be incorporated into physician’s medical record• Must be corroborated by other medical record entries• Must be signed & dated by physician & incorporated
into physician’s medical record Excerpt from comprehensive assessment, etc.
Expectation continues that HH obtain as much supporting documentation from physician’s medical record to assure HH eligibility criteria are met
PHYSICIAN FTF ENCOUNTERS
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• Practical process Continue to obtain signed physician FTF encounter
certification form• Form no longer needs physician composed narrative
Continue to obtain additional supporting documentation
• Physician encounter note, inpatient discharge summary, etc.
Provide additional supporting documentation to physician to incorporate into physician’s record
• Excerpt from comprehensive assessment, etc.
PHYSICIAN FTF ENCOUNTERS
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• Questions & concerns not yet addressed Will intensity level of pre- & post-pay medical review
focused on HH FTF compliance continue? If HH claim is denied for lack of FTF compliance will
physician claim for care plan oversight also be denied?Vice-versa?
If HH provides supporting documentation to physician to incorporate into physician’s record does HH need returned copy from physician to respond to HH pre- or post-payment medical review?
PHYSICIAN FTF ENCOUNTERS
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51SUMMARY
• 2015 summary New payment rates New transition CBSA codes PPS model changes New therapy reassessment requirements Physician FTF encounter changes
• Clarifications pending
SUMMARY
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CPE CREDIT
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2/27/2015
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QUESTIONS?
FOR MORE INFORMATION
THANK YOU!M. Aaron Little, CPAManaging Directormlittle@bkd.com
2/27/2015
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