Adjustments to the 30-Day Period Payment Rate

10.2 - Adjustments to the 30-Day Period Payment Rate (Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20) A. Case-Mix Adjustment A case-mix methodology adjusts the 30-day payment rate based on characteristics of the patient and his/her corresponding resource needs (e.g., diagnoses, functional impairment level, and other factors). The 30-day period payment rate is adjusted by a case-mix methodology based on information from home health claims, other Medicare claims, and data elements from the Outcome and Assessment Information Set (OASIS). The claims information and OASIS data elements are used to group 30-day periods of care into their case-mix groups. The following case-mix variables are obtained from home health or other Medicare claims: • Admission Source-Institutional (i.e., acute hospital, inpatient rehabilitation facility, skilled nursing facility, long-term care hospital, inpatient psychiatric facility) or Community; • Timing-Early (the first 30-day period of care) or Late (all subsequent 30-day periods of care, unless there is a gap of more than 60-days between the end of one period of care and the start of another), • Clinical Group-As determined by the principal diagnosis reported on home health claims; 30-day periods are assigned to one of 12 clinical groups describing the primary reason for the home health encounter: Clinical Groups The Primary Reason for the Home Health Encounter is to Provide: Musculoskeletal Rehabilitation Therapy (physical, occupational or speech) for a musculoskeletal condition Neuro/Stroke Rehabilitation Therapy (physical, occupational or speech) for a neurological condition or stroke Wounds – Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care Assessment, treatment & evaluation of a surgical wound(s); assessment, treatment & evaluation of non-surgical wounds, ulcers, burns, and other lesions Behavioral Health Care Assessment, treatment & evaluation of psychiatric and substance abuse conditions Complex Nursing Interventions Assessment, treatment & evaluation of complex medical & surgical conditions including IV, TPN, enteral nutrition, ventilator, and ostomies Medication Management, Teaching and Assessment (MMTA) MMTA –Surgical Aftercare Assessment, evaluation, teaching, and medication management for surgical aftercare MMTA – Cardiac/Circulatory Assessment, evaluation, teaching, and medication management for cardiac or other circulatory related conditions MMTA – Endocrine Assessment, evaluation, teaching, and medication management for endocrine related conditions MMTA – GI/GU Assessment, evaluation, teaching, and medication management for gastrointestinal or genitourinary related conditions MMTA – Infectious Disease/Neoplasms/Blood-forming Diseases Assessment, evaluation, teaching, and medication management for conditions related to infectious diseases, neoplasms, and blood- forming diseases MMTA –Respiratory Assessment, evaluation, teaching, and medication management for respiratory related conditions MMTA – Other Assessment, evaluation, teaching, and medication management for a variety of medical and surgical conditions not classified in one of the previously listed groups • Comorbidity Adjustment-As determined by certain secondary diagnoses reported on home health claims; a 30-day period of care can receive no comorbidity adjustment, a low comorbidity adjustment, or a high comorbidity adjustment. The following case mix variable is determined from responses to certain items on the OASIS assessment: • Functional Impairment Level-As determined by responses to certain OASIS items. A 30-day period of care can be assigned a low, medium, or high functional impairment level. Each 30-day period is assigned into one of 432 case-mix groups based on the variables described above. Each group’s case-mix weight reflects the predicted mean cost of the group relative to the overall average across all groups. B. Labor Adjustments The labor portion of the 30-day period payment rate is adjusted to reflect the wage index based on the site of service of the beneficiary. The beneficiary's location is the determining factor for the labor adjustment. The HH PPS rates are adjusted by the pre- floor and pre-reclassified hospital wage index. The hospital wage index is adjusted to account for the geographic reclassification of hospitals in accordance with §§1886(d)(8)(B) and 1886(d)(10) of the Social Security Act (the Act.) According to the law, geographic reclassification only applies to hospitals. Additionally, the hospital wage index has specific floors that are required by law. Because these reclassifications and floors do not apply to HHAs, the home health rates are adjusted by the pre-floor and pre- reclassified hospital wage index. NOTE: The pre-floor and pre-reclassified hospital wage index varies slightly from the numbers published in the Medicare inpatient hospital PPS regulation that reflects the floor and reclassification adjustments. The wage indices published in the home health final rule and subsequent annual updates reflect the most recent available pre-floor and pre-reclassified hospital wage index available at the time of publication.