There are some big changes proposed for the CY 2015 Home Health Prospective Payment System (HH PPS), released in the Federal Register on July 7, 2014. These proposed changes are in the final consideration and comments phase, in which CMS and HHS (Centers for Medicare and Medicaid Services and Health and Human services, respectively) will receive comments from the industry through September 2, 2014. After this comments phase, CMS will review all comments received and usually publishes a Final Rule in October each year outlining the final regulations and changes, most of which would go into effect January 1, 2015.
The proposed 2015 HH PPS Update outlines many of the usual updates, including information on rebasing adjustments, impacts of the Affordable Care Act, and changes to the Home Health PPS Case Mix weights. However, this year’s Federal Register includes some big changes for the Home Health Industry including changes to simplify the Face-to-Face Encounter requirements, changes to the Therapy Reassessment timeframes, changes to Home Health Quality Data, a revision to the Speech-Language Pathology personnel qualifications, Medicare coverage of insulin injections under HHPPS, and the delay of ICD-10-CM. There is also a call for comments on a Home Health Value-Based Purchasing Model. We will provide additional insights in other postings; however, we will touch on highlights of the significant ones in this article.
Face to Face Encounter
There are 3 changes being proposed; First of all, Medicare proposes to remove the narrative requirement from the F2F Encounter as currently in regulation. The F2F encounter was instated January 1, 2011 as a way to discourage physicians from relying on Home Health Agencies from being the primary source of information to physicians regarding a Medicare beneficiary’s home care needs and homebound status. The Face to Face Encounter is a means to ensure the physician is actively involved in deciding the skilled need required and why the patient is homebound.
Second, only records from the patient’s certifying physician or discharging facility (acute or post-acute) will be considered in determining initial eligibility for the Medicare home health benefit on medical review. If the patient’s medical record, used by the physician in certifying eligibility, was not sufficient to demonstrate that the patient was eligible to receive services under the Medicare home health benefit, payment would not be rendered for home health services provided.
Third, if a patient claim is denied because the beneficiary is ineligible for the home health benefit, then the physician claim for certification/re-certification of eligibility for home health services (not the face-to-face encounter visit) will be considered a non-covered service. This however, will be addressed under future guidance and is not part of regulation.
The proposed change would eliminate the need for a narrative statement; however, the physician or designated provider must continue to document the date of face to face encounter as well as a statement of why the patient requires skilled home health services and specific reasons the patient is homebound. The brief narrative requirement will continue to be required for all management and evaluation of Unskilled Care Plan, which is one of the four types of Skilled Nursing care. This narrative must describe the clinical justification of this need and must be located just above the physician’s signature on a Plan of Care or addendum to the Plan of Care. The M&E narrative requirement is also different in that it is required both at admission as well as each subsequent episode or recert. All other Face to Face Requirements are for the initial episodes only (the first in a series of episodes separated by no more than a 60 day gap).
Therapy Reassessment Timeframe Changes
The second change covered in this article is a proposed change in the Therapy Reassessment Requirements. Currently, all therapy services seeing a beneficiary during an episode must perform a Reassessment before the 14th and 20th therapy visit, as well as every 30 days. These reassessments may be completed as early as the 10th-13th visit and the 16-19th visit in areas designated as “rural” by CMS. Otherwise, they must occur in sequence just prior to the 14th and 20th therapy visit. The proposed change to the Therapy Reassessment Guidelines would mandate that therapy Reassessments occur at least once every 14 days regardless of the number of therapy visits provided. All other requirements in regard to the Reassessment would remain the same-the reassessment would have to be done by a qualified therapist rather than a therapy assistant, and the reassessment must be done per each therapy discipline involved on the case.
Home Health Quality Data
Another big change being proposed is the addition of two quality-based measures to the QRP/Home Health Compare Website Data List. These two quality measures are: 1) Re-Hospitalization of Beneficiary during the first 30 days of Home Health services and 2) Use of the Emergency Department without hospital readmission during the first 30 days of Home Health. We can deduce from this that CMS is definitely looking at the quality of care provided to beneficiaries by home health agencies. Time will tell if agencies will be penalized for these readmissions and/or ER use in the future, but certainly agencies should focus on these quality measures as they will be published to Medicare’s Home Health Compare website, which is available to the general public.
Speech-Language Pathology personnel qualifications
Currently CMS42 CFR 484.4 regulations state that a “speech-language pathologist” is “A person who:
1) Meets the education and experience requirements for a certificate of clinical competence (in speech pathology or audiology) granted by the American Speech-Language-Hearing Association; or
2) Meets the educational requirements for certification and is in the process of accumulating the supervised experience required for certification”.[1]
The proposed changes in the federal register article are that the Speech-language pathologist is a person who has a Master’s or Doctoral degree in speech-language pathology and who meets either of the following requirements:
A) Is licensed as a Speech-Language Pathologist in the state in which they are furnishing services
B) If the state they furnish services in does NOT license Speech-Language Pathologists, then the SLP
1) Must have successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience)
2) Must have performed not less than 9 months of supervised Full Time Speech Language Pathology services after obtaining a Masters or Doctoral degree in Speech-Language Pathology or a related field and
3) Successfully completed a national exam in Speech-Language Pathology approved by the Secretary.[2]
Insulin Injections under HHPPS
Medicare coverage of home health visits solely for the purpose of insulin administration is intended and limited to those patients who are physically and mentally unable to self-inject and have no willing and able caregiver to inject the patient. Outlier payments in excess of $10,000 had on average 160 SN visits in a 60 day episode of care. 95% of these outlier episodes listed Diabetes or Long-Term Use of Insulin as primary diagnosis. CMS did further research and found that in 49% of the episodes reviewed, there was no secondary diagnosis that supported the patient’s mental or physical disability causing inability to self-inject. In initial episode, the percentage went up to 67% of episodes lacking secondary supporting diagnoses.
CMS clinical staff and experts compiled a list of ICD-9-CM diagnosis codes that indicate impairments indicative of inability to self-inject insulin. These diagnoses include impairments in dexterity (such as paralysis or arthritis), cognition, vision and/or hearing. This list of diagnoses can be found on Table 28[3] on the proposed changes notice. While no policy changes are proposed at this time, public comments are welcome as to the list of diagnoses published. CMS is evaluating whether or not this list is comprehensive as to the supporting reasons diabetic patients cannot self-inject insulin.
CMS does intent to continue monitoring claims for the sole purpose of insulin injections, and will expect historical evidence in the chart to support the clinical legitimacy of the secondary conditions and resulting disability that limits the beneficiary’s ability to self-inject. This would include detailed clinical findings by the clinician and physician, as well as use of secondary ICD-9-CM codes on the OASIS and Claim forms that supports documentation as to why the patient cannot self-administer his or her own insulin. Documentation should also show that attempts have been made to identify and train a caregiver to administer the insulin for the patient, and/or why an insulin pen would not be a solution for the patient.
Delay of ICD-10-CM
The Secretary announced on May 1, 2014 that HHS (Health and Human Services) expects to issue an interim final rule that will require agencies to continue using ICD-9-CM codes until September 30, 2015 and the use of ICD-10-CM beginning October 1, 2015. Diagnosis reporting on Home Health claims must adhere to ICD-9-CM coding conventions and guidelines regarding selection of principal diagnosis and the reporting of additional (secondary) diagnoses until October 1, 2015.
Home Health Value-Based Purchasing Model
Value Based Purchasing Models (VBPs) are intended to tie payment to the provider’s performance in order to decrease inappropriate or poorly furnished care and identify and reward those who furnish quality care to beneficiaries. Section 3006(b)(1) of the Affordable Care Act directed the Secretary to develop plan to implement a VBP program for Home Health Agencies and issue a report to Congress. This report stated that the VBP should be built on existing and refined existing quality measurement tools and processes. The report also indicated that one way to link payment to quality would be to tie payments to overall quality performance.
CMS has already implemented the Hospital Value Based Purchasing model (HVBP) wherein 1.25% of hospital payments in FY2014 are tied to the quality of care provided. This percentage will increase to 2% in FY2017 and subsequent years. The President’s 2015 Budget proposes that value based purchasing should be extended to Skilled Nursing Facilities, Home Health Agencies, Ambulatory Surgical Centers, and Hospital Outpatient Departments. As currently envisioned, the HHA VBP model would reduce or increase Medicare payments in a 5-8% range depending on the degree of quality performance in measures to be selected.
If CMS decides to move forward with the implementation of this HHA VBP model in CY2016, they intend to invite additional comments on a more detailed model proposal to be included in future rulemaking.
To make comments on proposed changes, agencies may submit comments in one of four ways listed on page 2 of the Federal Register Article.[4]
[1] http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_b_hha.pdf
[2] http://www.gpo.gov/fdsys/pkg/FR-2014-07-07/pdf/2014-15736.pdf, p55
[3] http://www.gpo.gov/fdsys/pkg/FR-2014-07-07/pdf/2014-15736.pdf, pp.40-42
[4] http://www.gpo.gov/fdsys/pkg/FR-2014-07-07/pdf/2014-15736.pdf
