2020 Medicare Home Health PPS Proposed Rule

August 5, 2019

This home health proposed rule’s 346 pages (reduced from last year’s 600) were published on July 18. Comments will be accepted from now until September 9, 2019. You can submit your comment by clicking on the “Submit a formal comment” link near the top of the article. You can also send your comments by regular mail or express/overnight mail using the addresses referenced on page 3 of the rule. Make sure you include the file code CMS-1711-P or your comment may not be considered.

Home Health Prospective Payment System (HH PPS) Updates

For episodes that begin in 2019 and end in 2020, the 60-day episode methodology still applies and there is a 60-day episode rate update. The base rate will be increased to $3,221.43 – calculated as the $3,154.27 amount in 2019 increased by the wage index budget neutrality factor of 1.0062 and the market basket increase of 1.5%. Case-mix calculation equations will not change since these episodes will be phased out by February 28, 2020. 60-day period case-mix weights will carry over from 2019 and will not be recalibrated. The 2% payment reduction for non-submission of quality data continues to apply to both HH PPS and PDGM. The fixed dollar loss ratio for outliers will remain at 0.51.

Patient-Driven Groupings Model (PDGM)

CMS is going forward with the Patient-Driven Groupings Model (PDGM)effective for home health episodes starting January 1, 2020 or later. It is mostly intact from the blog post we published in March with a notable exception and a few clarifications.

The exception concerns RAP payments. Due to a number of fraud cases exploiting the RAP system and the delay in RAP submission by agencies to around 12 days per episode, CMS is proposing that agencies that were certified before January 1, 2019 receive a 20% RAP payment with the remaining 80% paid at the end of the 30-day payment period in calendar year 2020. Agencies that were certified after January 1, 2019 will still receive no payment for the RAP but will be required to file the RAP for informational purposes. Starting January 1, 2021, RAPs will be phased out for all agencies and they will be required to submit a Notice of Admission (NOA) similar to hospice’s Notice of Election. Agencies will have 5 days to submit the NOA or risk a penalty of 1/30th of the episode value for each day the NOA is late which would be considered provider liability and could not be billed to the patient. See more information about the RAP phase-out and NOA here.

The first clarification is in the calculation of the PDGM HIPPS code – non-routine supplies will no longer have a separate domain in the HIPPS code but will be included in the base payment amount for the case-mix rates. Also, only one comorbidity adjustment (the highest applicable) will apply to each 30-day period.

The final clarification is when an “Other Follow-Up” OASIS is required. The OASIS will be necessary to report a change in functional domain but any diagnosis changes will be processed from the claim submission so no additional OASIS assessment need be completed unless the clinical condition of the patient requires it. Because of this, claim and OASIS diagnoses will not be expected to match in all cases.

PDGM 30-day period payments

The base rate for 30-day periods in calendar year 2020 is proposed to be $1,791.73. This amount came from the estimated 30-day payment amount of $1,907.11 reduced by an 8% behavioral payment adjustment to $1,754.37 and increased by the wage index budget neutrality factor of 1.0062 and the market basket update of 1.5%.

Case-mix weights for the 432 PDGM payment groups will be calculated using a 4-step approach. The new HIPPS codes and weights can be reviewed in Table 14 of the Rule. Case-mix weights range from 0.4935 for HIPPS code 3GA11 (late community MMTA surgical aftercare with low functional domain and no comorbidity) to 1.8646 for HIPPS code 2CC31 (early institutional Wound with high functional domain and comorbidity interactions).

Outlier and PEP adjustments will function similar to PPS except that they will be scaled to 30-day payment periods and the outlier fixed dollar loss ratio will be increased to 0.63 for 30-day periods of care. LUPA thresholds range from 2 to 6 depending on the 10th percentile value of visits for each case-mix group. If the number of visits is less than the established LUPA threshold, the period is not subject to a LUPA adjustment. So, if the LUPA threshold is two and the agency performs two or more visits, the agency will receive the full 30-day period payment amount. 2020 per-visit LUPA amounts can be found here in the Rule.

The rural add-on payment will continue in 2020 but will be reduced by 1% for all areas. This means “High utilization” areas rate will be 0.5%, “low population density” areas rate will be 3.0% and all other rural areas will be 2.0%.

Allow assistants to perform maintenance therapy

If you’re still with me after all that financial talk, you’ve arrived at one of the highlights of the Proposed Rule. CMS is considering allowing physical therapy assistants and occupational therapy assistants to perform maintenance therapy visits. This could provide better access to care for maintenance therapy patients in areas with clinician shortages and better aligns with skilled nursing facility practice. Obviously, the physical therapist or occupational therapist will still be required to complete the assessment, plan of care, and reassessment every 30 days. Review here for more information.

Home Health Value-Based Purchasing (HHVBP)

The purpose of Home Health Value-Based Purchasing (HHVBP) is to provide incentive to agencies to improve quality and delivery of home health services. Agencies in states participating in the model will receive payment adjustments up to a 6% increase or decrease depending on performance metrics. Total Performance Scores (TPS) are awarded based on OASIS, HHCAHPS, claims and web portal submissions. Agency TPS and percentiles from calendar year 2020 would be publically reported after December 1, 2021 after the agency appeal process and agency receipt of their final Annual Report. For more information on HHVBP see the Rule here or the CMS Home Health Value-Based Purchasing Model website.

Home Health Quality Reporting Program (HH QRP)

For a list of measures for calendar year 2021, please see Table 26 of the Rule. CMS is planning on removing the “Improvement in Pain Interfering with Activity” measure from HH QRP beginning with calendar year 2022 under Factor 7: Collection or public reporting of a measure leads to negative unintended consequences other than patient harm. This decision came as part of CMS’ overall efforts to address the national opioid crisis and remove the unintended potential for over-prescription and utilization of opioids. Agencies could see the removal of the OASIS pain question (M1242) beginning January 1, 2021.

Two new measures are proposed for adoption in calendar year 2022. “Transfer of Health Information to Provider – Post-Acute Care” and “Transfer of Health Information to Patient – Post-Acute Care”. Both measures will focus on the delivery/receipt of a reconciled medication list at time of discharge or transfer. An explanation of these measures can be found here in the Rule, with details about the contents of a reconciled medication list here and calculation methodology here.

An update to exclude baseline nursing facility residents from the “Discharge to Community (DTC) – Post Acute Care (PAC)” quality measure is also proposed beginning with calendar year 2021 HH QRP.

Future Changes to OASIS Items

Other than M1242, there were several standardized patient assessment data elements (SPADEs) proposed for the OASIS which could begin as early as January 1,2021. Most of these SPADEs will apply to start of care (SOC), resumption of care(ROC) and discharge (DC) OASIS assessments. For detailed information, check out the Change Table for Proposed HH QRP Items or this section of the Rule. No specific instructions were given yet to address SOC only SPADEs when the SOC occurs before 2021. New SPADEs under consideration include:

Cognitive Function and Mental Status

  • New – Brief Interview for Mental Status (BIMS) – C0100, C0200, C0300, C0400, C0500
  • New – Confusion Assessment Method (CAM) – C1310
  • Replace M1730 – PHQ-2 to PHQ-9 would allow PHQ-9 if the PHQ-2 assessment demonstrated symptoms that required additional screening – D0150, D0160

Special Treatments, Services and Interventions

  • New – Cancer Treatment: Chemotherapy – O0110 A
  • New – Cancer Treatment: Radiation – O0110 B
  • New – Respiratory Treatment: Oxygen Therapy – O0110 C
  • New – Respiratory Treatment: Suctioning – O0110 D
  • New – Respiratory Treatment: Tracheostomy Care – O0110 E
  • New – Respiratory Treatment: Non–invasive Mechanical Ventilator – O0110 G
  • New – Respiratory Treatment: Invasive Mechanical Ventilator – O0110 F
  • New – Intravenous (IV) Medications – O0110 H
  • New – Transfusions – O0110 I
  • New – Dialysis – O0110 J
  • Replace M1030 – Intravenous (IV) Access – O0110 O
  • Replace M1030 – Parenteral/IV Feeding – K0520 A
  • Replace M1030 – Nutritional Approach: Feeding Tube – K0520 B
  • New – Nutritional Approach: Mechanically Altered Diet – K0520 C
  • New – Nutritional Approach: Therapeutic Diet – K0520 D
  • High–Risk Drug Classes: Use and Indication – N0415 (SOC/ROC) and N0420 (DC)

Medical Condition and Comorbidity Data

  • New (Removing M1242) – Pain Interference: Pain Effect on Sleep – J0510
  • New – Pain Interference with Therapy Activities – J0520
  • New – Pain Interference with Day-to-Day Activities – J0530

Impairment Data

  • New – Hearing – B0200 – SOC only
  • Replace M1200 – Vision – B1000 – SOC only

Social Determinants of Health

  • Replace M0140 – Ethnicity – A1005 – SOC only
  • Replace M0140 – Race – A1010 – SOC only
  • New – Preferred Language/Interpreter Services – A1110
  • New – Health Literacy – B1300
  • New – Transportation – A1250
  • New – Social Isolation – D0700

Medication List Reconciliation

  • New – Provision of Current Reconciled Medication List to Subsequent Provider at Discharge – A2121 A – DC only
  • New – Provision of Current Reconciled Medication List to Subsequent Provider at Transfer – A2121 B – Transfer only
  • New – Route of Current Reconciled Medication List Transmission – A2123 – Transfer or DC only

CMS is also considering mandatory reporting of OASIS data on all patients regardless of payer. This would require agencies who are using an alternative means of assessing non-Medicare/Medicaid patients to begin using and submitting OASIS data so that performance scores would reflect the full patient population of the agency. CMS is only seeking input at this time and no effective date has been set.

Change to HHCAHPS Survey

CMS is proposing to remove Question 10 from the HHCAHPS survey which asks about whether the agency spoke with the patient about pain. This aligns with the removal of the pain frequency question in the OASIS to address the national opioid epidemic.

Home Infusion Therapy

There is a new Medicare benefit covering home infusion therapy provision. This service covers clinical services (primarily nursing), patient training and education, remote monitoring, and home infusion drugs provided by a home infusion therapy supplier to the patient in their home. Services would be provided under a plan of care with payment defined in 3 payment categories dependent upon the complexity of the drug administration with a limit of 5 hours that can be billed per day.

Home health agencies need to know that during the transitional period from 1/1/2019 through 12/31/2020, home health is responsible for providing or arranging for home infusion services and bill them as home health services. If an agency cannot provide needed home infusion therapy services, they are expected to discharge the patient to an agency that can meet their needs. After January 1, 2021, home infusion services will be recognized as a separate Part B service that can be provided concurrently but separately from home health.

This is only the tip of the iceberg on information about home infusion therapy services. If this line of service applies to your agency, you should carefully review the home infusion therapy section of the Rule.

So What Does This All Mean?

PDGM and OASIS changes are going to happen. Your agency should already be ensuring that intake is capturing all inpatient and post-acute stays prior to admission and reviewing diagnosis codes received from referral sources to identify diagnoses that do not fit into a Clinical Grouping category.

CMS wants to be able to view and compare data across the post-acute care continuum and this requires we all “speak the same language”. Changes to the OASIS directly reflect updates to other post-acute standardized assessments. It is vital that your clinicians can be independent in understanding and completing OASIS documents and verifying referral information such as institutional stays and diagnosis codes.

Agencies should evaluate the timeframe from date assessment completed on the OASIS to date the RAP is filed to identify whether operational processes need to be made more efficient and avoid late NOA filing penalties. The good news is that there is some time to make these adjustments – but agencies should not delay.

The Wrap-Up

therapyBOSS will continue to provide fully compliant documentation including the most current OASIS data sets as they become effective. We will monitor the progression of the new OASIS-E data set and will ensure it is available for use on the implementation date. You can expect to see another article about OASIS-E once it is finalized. We will also monitor whether CMS allows assistants to provide maintenance therapy services and update our system to allow PTAs and COTAs to perform follow-up maintenance therapy visits if the proposed rule becomes final.

It is essential that you make your voice heard. Whether you agree with them or not, CMS needs your input to understand the true impact of their legislation on the people who work in the industry. Please make sure to give your comments before September 8, 2019 to ensure they will be considered.

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