OASIS and the Home Health Prospective Payment System

2202.7 - OASIS and the Home Health Prospective Payment System (PPS) (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) The home health PPS helps to ensure appropriate reimbursements for quality, efficient home health care. Under prospective payments, Medicare pays HHAs a predetermined base payment. This payment is adjusted for the health condition and care needs of the beneficiary. The payment is also adjusted for the geographic differences in wages for HHAs across the country. This and other PPS information is available on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/HomeHealthPPS/index.html. The following are highlights of the home health PPS system: • Episode - Medicare pays HHAs for each covered 60-day episode of care. As long as beneficiaries continue to remain eligible for home health services and episodes are not overlapping and are medically necessary, they may receive an unlimited number of episodes of care. Payments cover skilled nursing, home health aide visits, covered therapy, medical social services and routine and non-routine medical supplies. • Home Health Resource Groups (HHRG) - A case mix methodology adjusts payment rates based on characteristics of the patient and his/her corresponding resource needs (e.g., diagnosis, clinical factors, functional factors, and service needs, etc.). The 60-day episode rates are adjusted by case mix methodology based on payment policy data elements from the OASIS. The data elements of the case mix adjustment methodology are organized into several dimensions such as clinical severity factors, functional severity factors, and service utilization factors resulting in Home Health Resource Groups (HHRG), a patient payment classification described as case mix. • Request for anticipated payment (RAP) - To ensure adequate cash flow to HHAs, the home health PPS has set forth a split percentage payment approach to the 60- day episode. The split percentage occurs through the request for anticipated payment (RAP) at the start of the episode and the final claim at the end of the episode. For the initial episode, there is a 60/40-split percentage payment. An initial percentage payment of 60 percent of the episode is paid at the beginning of the episode and a final percentage payment of 40 percent will be paid at the end of the episode, unless there is an applicable adjustment. For all subsequent episodes for beneficiaries who receive continuous home health care, the episodes are paid at a 50/50 percentage payment split. • Outlier - Additional payments will be made to the 60-day case-mix adjusted episode payments for beneficiaries who incur unusually large costs. These outlier payments will be made for episodes whose imputed cost exceeds a threshold amount for each case-mix group. The amount of the outlier payment will be a proportion of the amount of imputed costs beyond the threshold. Total national outlier payments for home health services annually will be no more than a fixed percent of estimated total payments under home health PPS. • Partial episode payment (PEP) - The partial episode payment allows the 60-day episode clock to end and a new clock to begin if a beneficiary transfers to another HHA or is discharged with goals met but returns because of a decline in their condition to the same HHA within the 60-day episode. When a new 60-day episode begins, a new plan of care and a new assessment are necessary. The original 60-day episode payment is proportionally adjusted to reflect the length of time the beneficiary remained under the agency's care before the intervening event. The new episode is paid an initial episode payment rate. The 60 day clock is restarted. • Consolidated billing - Under the PPS a HHA must bill for all Medicare home health services which includes nursing and therapy services, routine and non- routine medical supplies, home health aide and medical social services, except durable medical equipment (DME). DME is excluded from the consolidated billing requirement. The law requires that all home health services paid on a cost basis be included in the PPS rate. Therefore, the PPS rate will include all nursing and therapy services, routine and non-routine medical supplies, and home health aide and medical social services. • Low Utilization Payment Adjustment,” (LUPA) - An episode with four or fewer visits is paid as a LUPA, which is the national per visit amount by discipline adjusted by the appropriate wage index based on the site of service of the beneficiary. Such episodes of four or fewer visits are paid the wage adjusted per visit amount for each of the visits rendered instead of the full episode amount. Beginning January 1, 2008, an additional payment is made for the first visit in a LUPA episode. Payment rule refinements often impact policy and are published annually at: http://www.cms.gov/Center/Provider-Type/Home-Health-Agency- HHA-Center.html. Exceptions to OASIS Collection and Reporting Procedures Under PPS There are some exceptions to the general OASIS collection and reporting procedures that are unique to Medicare PPS patients. There is information on the OASIS Web site that is provided to help HHAs integrate the home health PPS into their existing OASIS data collection procedures. A summary of that information with regard to OASIS data collection and the appropriate M0100 (Reason for Assessment) and M2200 (Therapy Need) response selection is provided below. A - PPS Start-up For new patients after October 1, 2000, any applicable (skilled care) patients (not just Medicare patients) accepted for care on or after October 1, 2000, are assessed according to the established time points at §484. EXAMPLE: A patient whose SOC date is October 15 would be re-assessed for the need to continue services for another certification period during the last 5 days of the current 60-day certification period. In this example, the follow-up assessment would be conducted during the period 12/9/00 through 12/13/00. B. First 60-day Episode SOC: M0100 = RFA 1 and M2200 = 0-No or 1-Yes. C. New 60-day Episode Resulting From Discharge With All Goals Met and Return to Same HHA During the 60-Day Episode. (PEP Adjustment) SOC: M0100 = RFA 1 and M2200 = 0-No or 1-Yes. D. New 60-Day Episode Resulting From Transfer to HHA With No Common Ownership (PEP Adjustment to Original HHA) PEP Adjustment does not apply if patient transfers to HHA with common ownership during a 60-day episode. Receiving HHA completes OASIS, as applicable, on behalf of transferring HHA. Transferring HHA serves as the billing agent for the receiving HHA. Transferring HHA may continue to serve as the billing agent for receiving HHA or conduct a discharge assessment at end of episode. Receiving HHA starts new episode with SOC (if original HHA discharges at end of episode): M0100 = RFA 1 and M0825 = 0-No or 1-Yes. E Subsequent 60-Day Episode Due to the Need for Continuous Home Health Care After an Initial 60-Day Episode Recertification (Follow-up): (M0100) = RFA 4 and (M2200) select 0-No or 1-Yes. F. Patient’s Inpatient Stay Extends Beyond the End of the Current Certification Period. (Patient Returns to Agency After Day 60 of the Previous Certification Period) SOC: M0100 = RFA 1 and M2200 = 0-No or 1-Yes. When patient returns home, new orders and plan of care are necessary. At time of transfer to an inpatient facility, the HHA completes the transfer. If transferred without discharging, a new episode is started and a new SOC assessment is completed when the patient returns home.