1. Please explain how patient recertifications are handled in the final few days of 2019. Are they reimbursed under PPS or PDGM?
Recertification OASIS completed between December 27-31, 2019, for episodes beginning January 1, 2020, or after will be completed on OASIS D-1 and will require an artificial date of 01/01/2020 in M0090. These OASIS (with artificial date of 01/01/2020) should not be exported until on or after January 1, 2020.
Recertifications completed between December 27-30, 2019 for an episode beginning prior to January 1, 2020, will continue to be paid under home health Prospective Payment System (PPS), and will be completed using OASIS D with the ACTUAL date of completion stated in M0090.
2. Will there be new OASIS requirements beginning January 1, 2020?
Yes, OASIS D-1 will be used for episode dates beginning on or after January 1, 2020. To satisfy the needs of PDGM, additional items were added to the Recertification (M1033 Risk for Hospitalization and M1800 Grooming) while responses to items used for PPS have been made optional.
3. Where are we going to send the NOA?
The requirements for the Notice of Admission will not begin until 2022. CMS has not yet announced how the NOA will be processed.
4. With the heavy presence of home health in assisted living (AL) communities (many using home health aides and nursing to supplement their own staff) and with most AL being Late/Community referrals, what impact will PDGM have on these communities and how should they be preparing?
Home health service eligibility requirements have not changed because of PDGM. Agencies should provide medically necessary, outcomes-focused care based on the patient’s needs. Late/Community referrals may focus on ongoing disease processes and chronic comorbid conditions, so focusing on industry best practices for managing these types of patients, including practicing to the top of professional licenses and coordinating care with agency and assisted living communities should be top of mind.
5. How do we predict the impact of PDGM on our agency?
Agencies would be wise to use claims data in the form of an impact analysis to analyze their greatest potential impacts. This data can be used to predict the areas in which policies should be refined as well as opportunities for improvement and success. CMS provides historical information on their website. More information can be found for related questions in the Regulatory section of the FAQs.
Axxess clients may use the PDGM Impact Analysis tool located under the PDGM tab above their Dashboard to predict the impact of PDGM on their agency.
6. Is maintenance therapy payable under PDGM?
Yes. Where clinically appropriate, therapy services may provide maintenance therapy under the home health benefit. According to the Final Rule that was recently released, Physical Therapy Assistants (PTAs) and Occupational Therapy Assistants (COTAs) may now provide maintenance therapy visits as well. Maintenance therapy is not documented or billed any differently, rather it is the practice of continuing to provide therapy services for patients in order to keep patients and their caregivers safe, and to slow the process of decline. Maintenance therapy can be used with a wide variety of chronic illnesses, for example, Parkinson’s Disease and Multiple Sclerosis, where the likelihood of a patient making measurable improvements is limited.
Axxess clients can ensure compliance and protect revenue using the Axxess tools below when documenting and planning care using maintenance therapy as a skill.
7. How can agencies identify and flag QECs?
Axxess’ home health software will alert you to primary diagnosis codes that would trigger an Ungroupable Diagnosis or QE. Axxess has a wealth of resources available including a list of commonly used Questionable Encounter Codes available to download. These resources can be accessed at www.axxess.com/pdgm
Axxess clients are currently provided a warning at Intake if a QEC is used. Beginning January 1, 2020, the warning will be a hard stop if the patient is a Medicare patient in order to protect the agency’s revenue under the new requirements for PDGM reimbursement.
8. For payment purposes, is it better to keep patients for 60 days or discharge at the end of 30 days?
Where clinically appropriate, there may be an advantage to an increased length of stay. For example, a PT frequency of 2W4 would concentrate all the visits in to the first 30-day payment period. If it would be beneficial to the patient (e.g. still meet their goals, maintain their safety, and achieve good outcomes), a visit frequency of 2W3 followed by 1W3 may be an alternative to consider. The same mapping and appropriate planning of visits is important for all disciplines.
Axxess clients can see their revenue for both 30-day periods using the PDGM Modeling Tool. In addition, they can see the total operating income by using the Gross Margin Calculator as shown below.
9. How does PDGM affect current frequency and duration?
Where clinically appropriate, there may be an advantage to an increased length of stay. Frequency and Duration of visits should be based on a patient-centered assessment using the professional process, and based on the number of skilled, medically necessary interventions and goals. Agencies are encouraged to use best practices to dictate policies for determining frequency and duration, such as clinical pathways.
10. Is Medicare going to pay for home health aides in 2020?
Home Health Aide (along with SN, PT, OT, ST, and MSW) visits remain one of the disciplines covered in the Home Health benefit when reasonable and necessary. Home Health Aide visits also contribute to the LUPA thresholds count.
11. How many diagnoses should be addressed in the plan of care?
All diagnoses that are not resolved, and require intervention during the home health episode, or that have the potential to impact the care being provided, should be listed on the Plan of Care. CMS will be able to view up to 24 secondary diagnoses on the claim information for possible comorbidity payment adjustment, and all codes that are listed must be included on the Plan of Care as requiring intervention or having the potential to impact the services being provided.
12. We are gathering data regarding our clinical groupings, hospitalizations, comorbidities, and functional impairment. How do we coordinate all together with actions we should take?
It is certainly wise to study your agency’s past performance to see where the PDGM payment system offers opportunities to make modifications. Depending on your agency-specific findings, the agency could develop strategies including focused marketing of specialty programs, improved or outsourcing of ICD-10 coding, fall prevention programs, or enhanced OASIS education. If you do not feel as though you have the internal resources, please consider reaching out to clinical consultants or professional services experts.
In addition to the multiple PDGM tools provided within the Axxess software, consulting services will be offered through Axxess beginning in 2020. PDGM Agency Operational Playbook is an individualized plan of action for agencies to thrive under PDGM. For more information, email PDGMquestions@axxess.com.
13. Can a WOCN use telehealth to consult on wounds?
Yes. Because of the expansion of the one-clinician rule, WOCNs can use telehealth or telemonitoring to collaborate on OASIS items and consult on appropriate wound care patients. For collaboration, CMS has specified that the collaborating professional must have had patient contact within the timeframe specified. They went on to state that telehealth is considered patient contact in this specific example. This is an efficient use of resources, but remember, telehealth visits are not reimbursable.
14. What are the best reports to use for PDGM?
A deep understanding of how your current practices and processes will be impacted by PDGM will help you identify areas of focus. High on the list of processes to understand is the need to identify coding practices that need to change in order to avoid Questionable Encounters. It is also important to understand the other aspects of PDGM, including how you will be impacted by episodes that have a length of stay of fewer than 30-days, the distribution of patients among the Functional Deficit thresholds, and the impact of comorbidities. Our home health software users currently have easy access to this information and much more in the new PDGM Center.
15. What is the impact of community referrals on an agency less than 50?
Regardless of size of the agency, there will be a lower reimbursement for patients who have not been in an institution in the preceding 14 days. This adjustment occurs due to data illustrating patients who were recently discharged from a facility are more acutely ill and require additional resources. Because of the lower reimbursement, smaller size agencies may need to adjust by maximizing the efficiency of each visit, assure that they are appropriately scoring the OASIS to receive the appropriate Functional Deficit adjustment, and coding accurately in order to be assigned to the correct Clinical Group for comorbidity adjustments.
16. How do we move from one 30-day period to another 30-day period?
There are no requirements to complete additional OASIS or re-certification assessments. Agencies may choose to adopt a policy of re-assessing patients near the 30-day mark to assure that care should be continued and that the visit plan is appropriate to avoid unnecessary LUPAs.
Axxess clients should use the Change of Focus form pictured below in order to ensure compliance with updating the plan of care and maximize revenue through the automation of changing the primary diagnosis on billing claim forms.
17. We have discussed PT/OT use, what about speech therapy? Where does ST come in to play in functional scoring? Are these OASIS items based only on motor skills, ADLs, and self- care?
The OASIS items that are considered for functional scoring are listed below. These items cover a gamut of ADLs, and OASIS guidance mandates that the cognitive abilities of the patient, as well as the physical abilities, must be considered when answering these items. Per OASIS guidance, Speech Therapists can complete OASIS assessments.
The functional impairment portion of PDGM is based on the following OASIS items:
M1800 – Grooming
M1800 – Dressing Upper Body
M1820 – Dressing Lower Body
M1830 – Bathing
M1840 – Toilet Transferring
M1850 – Transferring
M1860 – Ambulation/Locomotion
M1033 – Risk for Hospitalization
18. What considerations for operations would you recommend when the second 30-day billing period’s diagnosis changes from the first billing period without OASIS? What should the agency do as it relates to the plan of care, orders, and claim?
If the agency’s software does not have a system to change the clinical grouping, the agency will need to develop manual operations to notify billing when there is a clinical grouping change. The agency should identify in their documentation that the focus of care has changed to the new diagnosis and clinical grouping and explain why. This can be documented in a wide variety of ways to include inclusion on the clinical care note, care coordination note and/or team conference. If orders are already on the existing plan of care for the new clinical grouping, new orders will not be required.
Axxess clients should use the Change of Focus Form pictured and discussed above in question 16.
19. In the live seminar presentation, it was stated that therapy utilization of 8-10 visits will create a profit margin. Is this 8-10 in a 30- day period or 60-day period?
The statement made indicated that in many cases the PDGM reimbursement that would be paid over the two combined payment periods (provided that neither payment period becomes a LUPA) is at a similar level to the reimbursement that is currently paid under PPS for a patient receiving 8-10 therapy visits.
20. Rehab Aides are mentioned multiple times. What are these and are they reimbursable by Medicare?
“Rehab Aides” is a term coined for the use of Home Health Aides who have received additional training and competency evaluations to perform certain non-skilled rehab care to include assistance with home exercise programs, assessment of environment for safety concerns, assessment of DME equipment for safety concerns, and assistance with ambulation. There are restrictions in many states about Rehab Aides providing hands on rehab care, such as massage or Passive Range of Motion (PROM). These visits would be included and billed as home health aide visits and are therefore reimbursable by Medicare. Practice restrictions may vary on a state by state basis.
21. What visit frequency would you recommend for therapy under PDGM?
The best advice is to provide the care that the patient needs to meet their goals, to optimize their safety, and to restore function. Just as is the case with PPS, there will be payment periods where the agency profits and those where there is a loss. Many agencies who have been providing an appropriate level of therapy care will see minimal change in their practices under PDGM. A dramatic reduction in the volume of therapy visits provided will be an indicator to post-payment review entities that an unnecessary level of therapy was being provided under PPS. There must be a focus on showing quality, measurable outcomes.
22. At the end of the 30-day episode, does the RN do another recert?
To continue skilled care, an OASIS Recertification is required every 60 days, but no Recertification is required at the end of the 30-day billing period. It is advisable practice to have a case-conference type meeting near the end of the 30-day payment period to plan visits and to collaborate on continued care.
23. Do we need to pay for telemonitoring visits?
Telemonitoring is considered a cost of the agency to do business. It is not reimbursed by Medicare but can be included on the Medicare cost reports. Unless the patient has another source of payment for telemonitoring, the agency would need to pay for this service. Some state Medicaid programs will pay for telemonitoring. For patients who are dual eligible, they can and should bill Medicare for home health services and Medicaid for telemonitoring services simultaneously.
24. Should agencies call the hospitals on or prior to the weekend to check on discharges?
Many patients are discharged on the weekend and a suggested best practice would include phone calls to track patients on the weekend.
25. What are some examples that fall under the complex nursing grouping?
Some examples would include: Colostomy malfunction (K94.03), Infection of incontinent external stoma of urinary tract (N99.521), Leakage of infusion catheter, sequela (T82.534S), and Encounter for fitting and adjustment of urinary device (Z46.6).
26. What are some examples that fall under the behavioral health grouping?
Some examples would include: Unspecified dementia with behavioral disturbance (F03.91), Paranoid schizophrenia (F20.0), Major depressive disorder, recurrent, unspecified (F33.9), and Suicide attempt (T14.91).
27. If a nurse and therapist perform a visit together, will that impact billing?
Generally, only one visit is billable at a time (during the same time in/time out) unless medical necessity is proven. Therefore, only one visit would count toward the LUPA threshold.
28. What are the qualifications of a psych nurse under NGS as intermediary?
• An RN with a master’s degree with a specialty in psychiatric or mental health nursing and licensed in the state where practicing would qualify. The RN must have nursing experience (recommended within the last three years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
• An RN with a bachelor’s degree in nursing and licensed in the state where practicing would qualify. The RN must have one year of recent nursing experience (recommended within the last three years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
• An RN with a diploma or associate degree in nursing and licensed in the state where practicing would qualify. The RN must have two years of recent nursing experience (recommended within the last three years) in an acute treatment unit in a psychiatric hospital, psychiatric home care, psychiatric partial hospitalization program or other outpatient psychiatric services.
29. Does CMS require an OASIS on infusion patients, private pay patients and pro bono patients?
Any patient who is cared for by an agency under a Medicare license must receive a comprehensive assessment, which according to the Conditions of Participation, includes an OASIS. The only exceptions to the OASIS requirement are those patients who are under the age of 18, maternity patients, or those who require non-medical services only.