2015 HOME HEALTH MEDICARE PAYMENT ... 1 2015 HOME HEALTH MEDICARE PAYMENT & REGULATORY UPDATES –...

2/27/2015

1

2015 HOME HEALTH MEDICARE PAYMENT & REGULATORY UPDATES – PART III

Billing & Physician Face-to-Face Encounters

February 26, 20152:00 p.m. – 3:00 p.m. CT

M. Aaron Little, CPAManaging Director

[email protected]

2/27/2015

2

• Participate in entire webinar• Answer polls when they are provided• If you are viewing this webinar in a group Complete group attendance form with

• Title & date of live webinar• Your company name• Your printed name, signature & email address

All group attendance sheets must be submitted to within 24 hours of live webinar

Answer polls when they are provided

• If all eligibility requirements are met, each participant will be emailed their CPE certificates within 15 business days of live webinar

TO RECEIVE CPE CREDIT

3

4OBJECTIVES

2/27/2015

3

• 2015 changes to Medicare home health (HH) Payment rates Core-based statistical area (CBSA) code changes Prospective payment system (PPS) model changes Therapy reassessments Physician face-to-face (FTF) encounter changes

• Payment validation tools

TODAY’S OBJECTIVES

5

62015 FINAL PAYMENT RULE

2/27/2015

4

• Medicare HH PPS final payment rule for 2015 Federal Register dated November 6, 2014

• http://www.gpo.gov/fdsys/pkg/FR-2014-11-06/pdf/2014-26057.pdf

Payment rate changes effective for episodes ending on & after January 1, 2015

2015 FINAL RULE

7

Federal Register dated December 2, 2014• http://www.gpo.gov/fdsys/pkg/FR-2014-12-

02/pdf/2014-28396.pdf• Correction notice clarifying new therapy reassessment

requirements effective for episodes beginning January 1, 2015

Change Request 8969 dated December 9, 2014• http://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/Downloads/R3145CP.pdf

• Summarizes rate changes

2015 FINAL RULE

8

2/27/2015

5

9PAYMENT RATE CHANGES

• All rate changes effective for episodes endingon & after January 1, 2015 2% sequestration reduction still applicable

• New national standard episode payment rates $2,961.38 urban rate $3,050.22 rural rate

• 3% rural add-on still applicable

PAYMENT RATE CHANGES

10

2/27/2015

6

• No changes to situations that result in penalties of 2% reduction in payment rates Nonsubmission of Outcome & Assessment

Information Set (OASIS) data Nonsubmission of HH Consumer Assessment of

Healthcare Providers (CAHPS) data


11

• No changes to labor or nonlabor ratios 0.78535 labor ratio 0.21465 nonlabor ratio

• No changes to outlier ratios 0.45 fixed dollar loss ratio 0.80 loss sharing ratio


12

2/27/2015

7

• New low utilization payment adjustment (LUPA) per-visit rates


Discipline Urban* Rural*

Skilled nursing (SN) $ 127.83 $ 131.66

Physical therapy (PT) 139.75 143.94

Occupational therapy 140.70 144.92

Speech-language pathology (SLP) 151.88 156.44

Medical social services 204.91 211.06

Home health aide 57.89 59.63

*All rates subject to wage-index adjustment

13

• No changes to LUPA payment add-on ratios 1.8451 SN ratio 1.6700 PT ratio 1.6266 SLP ratio


14

2/27/2015

8

New nonroutine medical supply (NRS) payment add-on rates


NRS Severity Level(HIPPS Code Character) Urban Rural

Level 1 (S or 1) $ 14.36 $ 14.79

Level 2 (T or 2) 51.86 53.42

Level 3 (U or 3) 142.19 146.46

Level 4 (V or 4) 211.25 217.60

Level 5 (W or 5) 325.76 335.55

Level 6 (X or 6) 560.27 577.11

15

16CBSA CODE CHANGES

2/27/2015

9

• Transition year for many counties From urban to rural, rural to urban or between urban

or rural areas Effective for episodes ended on & after January 1,

2015• New temporary billing codes to be used for all

transition counties Codes begin with “5”

• Episodes began in 2014 & ended in 2015 may require different CBSA code billed on final claim than request for anticipated payment (RAP)

CBSA CODE CHANGES

17

• Transition counties paid blended wage-index adjustment 50% of wage-index adjustment from both current

& prior classification

• Critical to identify billing codes for all counties Billing edits do not prevent incorrect CBSA codes

from being billed & paid

CBSA CODE CHANGES

18

2/27/2015

10

• Example 1 Washington County, Missouri

• Classified in CBSA “41180 St. Louis, MO” in 2014• Classified in CBSA “99926 Rural Missouri” in 2015• Billed with transition code “50090” in 2015

Paid blended wage-index adjustment of 0.8546• Episodes beginning in 2014 & ending in 2015

RAP billed with 41180 Final claim billed with 50090

• Paid rural national standard rate Including 3% rural add-on

CBSA CODE CHANGES

19

• Example 2 Scott County, Indiana

• Classified in CBSA “99915 Rural Indiana” in 2014• Classified in CBSA “31140 Louisville, KY-Jefferson

County, IN” in 2015• Billed with transition code “50040” in 2015

Paid blended wage-index adjustment of 0.8511• Episodes beginning in 2014 & ending in 2015

RAP billed with 99915 Final claim billed with 50040

• Paid urban national standard rate

CBSA CODE CHANGES

20

2/27/2015

11

• Example 3 Marin County, California

• Classified in CBSA “41884 San Francisco, CA” in 2014• Classified in CBSA “42034 San Rafael, CA” in 2015• Billed with new CBSA code “42034” in 2015

Paid wage-index adjustment 1.7260

• Episodes beginning in 2014 & ending in 2015 RAP billed with 41884 Final claim billed with 42034

• Paid urban national standard rate

CBSA CODE CHANGES

21

• HH PPS payment rate tables available on bkd.com for all CBSAs Requires following information

• Name• Organization• Email address• Rate year• CBSA code

PPS RATE TABLES

22

2/27/2015

12

23PPS MODEL CHANGES

• Severity scores• Grouper• Case-mix weights

PPS MODEL CHANGES

24

2/27/2015

13

• Severity scores New severity scoring methodology

• Patient characteristics coded on OASIS that have PPS payment value, i.e., severity scores Four different equations for calculating severity scores

• Grouped into Home Health Resource Groups (HHRGs) HHRGs are translated into HIPPS codes & matched to case-mix

weights

Applies to episodes beginning in 2015

PPS MODEL CHANGES

25

Patient characteristics coded on OASIS that generate severity scores & determine case-mix weight

• Episode timing• Clinical dimension

14 OASIS questions 45 scoring variables

• Functional dimension Seven OASIS questions Six scoring variables

• Service dimension Estimated number of therapy visits

PPS MODEL CHANGES

26

2/27/2015

14

PPS MODEL CHANGES

Patient Characteristic Severity Points

Coded on OASIS Equation 1 Equation 2 Equation 3 Equation 4

2014 Severity Scoring Variables

M1020 Primary diagnosis = diabetes 5 13 1 8

M1342 Surgical wound status = “2 Early/partial granulation” 0 2 3 0

2015 Severity Scoring Variables

M1020 Primary diagnosis = diabetes 0 8 0 7

M1342 Surgical wound status = “2 Early/partial granulation” 1 7 6 14

27

• Grouper Substantial changes in 2015 to PPS grouper

• Model for grouping severity scores into severity levels Clinical dimension severity level Functional dimension severity level Service dimension severity level

Applies to episodes ending in 2015

PPS MODEL CHANGES

28

2/27/2015

15

2015 Payment Grouping

Severity LevelHIPPSValue

1(Early)

2(Early)

3(Late)

4(Late)

5(Early or

Late)

Clinical Dimension Severity Points

C1 LowC2 ModerateC3 High

ABC

0 to 12 to 3

4+

0 to 12 to 7

8+

01

2+

0 to 56 to 12

13+

0 to 34 to 16

17+

Functional Dimension Severity Points

F1 LowF2 ModerateF3 High

FGH

0 to 1415

16+

0 to 34 to 13

14+

0 to 910

11+

01 to 7

8+

0 to 23 to 5

6+

Service Utilization Dimension Therapy Visits

S1S2S3S4S5

KLMNP

0 to 56

7 to 910

11 to 13

14 to 1516 to 1718 to 19

NoneNone

0 to 56

7 to 910

11 to 13

14 to 1516 to 1718 to 19

NoneNone

20+NoneNoneNoneNone

29



1(Early)

2(Early)

3(Late)

4(Late)

5(Early or

Late)



ABC

0 to 45 to 8

9+

0 to 67 to 14

15+

0 to 23 to 5

6+

0 to 89 to 16

17+

0 to 78 to 14

15+



FGH

0 to 56

7+

0 to 67

8+

0 to 89

10+

0 to 78

9+

0 to 67

8+


S1S2S3S4S5

KLMNP

0 to 56

7 to 910

11 to 13

14 to 1516 to 1718 to 19

NoneNone

0 to 56

7 to 910

11 to 13

14 to 1516 to 1718 to 19

NoneNone

20+NoneNoneNoneNone

30

2/27/2015

16

• Case-mix weights Substantial changes in 2015 to case-mix weights

• Ratio determined by OASIS assessment that determines episode payment Severity points are grouped into severity levels which are

matched to case-mix weights• All case-mix weights changed in 2015

Health Insurance PPS (HIPPS) codes unchanged• 0.4942 low• 2.2950 high

Applies to episodes ending in 2015

PPS MODEL CHANGES

31

PPS MODEL CHANGES

HIPPSCode

HHRGCode

EpisodeTiming

TherapyUtilization

Range

2015Case-mixWeight

2014Case-mixWeight

1AFKS C1F1S1 Early 0 0.5985 0.6080

3AFKS C1F1S1 Late 0 0.4942 0.4970

2AFKS C1F1S1 Early 14 to 15 1.2270 1.2049

4AFKS C1F1S1 Late 14 to 15 1.2407 1.2494

5AFKS C1F1S1 Early or late 20+ 1.8122 1.6745

32

2/27/2015

17

Source: CGS

33

• Example 1 Episode beginning in 2014 & ending in 2015

• RAP billed with HIPPS code “1AGPT” Paid based on case-mix weight 1.1738

• Early episode• Estimated 11 to 13 therapy visits

• Final claim paid with HIPPS code “1AGPT” Paid based on case-mix weight 1.1581

• Medicare Common Working File (CWF) confirmed episode status as early

• Billed 11 to 13 therapy visits on final claim

PPS MODEL CHANGES

34

2/27/2015

18

• Example 2 Episode beginning in 2014 & ending in 2015

• RAP billed with HIPPS code “1AGPT” Paid based on case-mix weight 1.1738

• Early episode• Estimated 11 to 13 therapy visits• “AFCHEICH” last eight characters of OASIS matching string

PPS MODEL CHANGES

35



1(Early)

2(Early)

3(Late)

4(Late)

5(Early or

Late)



ABC

0 to 45 to 8

9+

0 to 67 to 14

15+

0 to 23 to 5

6+

0 to 89 to 16

17+

0 to 78 to 14

15+



FGH

0 to 56

7+

0 to 67

8+

0 to 89

10+

0 to 78

9+

0 to 67

8+


S1S2S3S4S5

KLMNP

0 to 56

7 to 910

11 to 13

14 to 1516 to 1718 to 19

NoneNone

0 to 56

7 to 910

11 to 13

14 to 1516 to 1718 to 19

NoneNone

20+NoneNoneNoneNone

36

2/27/2015

19

• Example 2• Final claim paid with HIPPS code “4AHKT”

Paid based on case-mix weight 1.3730• Medicare CWF confirmed episode status as late• Billed 15 therapy visits on final claim• “AFCHEICH” last eight characters of OASIS matching string

Late episodes with 14 or more therapy visits falls into payment grouping “4”

“CH” indicating clinical & functional scores for payment grouping “4”• “C” = three clinical severity points• “H” = eight functional severity points

PPS MODEL CHANGES

37



1(Early)

2(Early)

3(Late)

4(Late)

5(Early or

Late)



ABC

0 to 12 to 3

4+

0 to 12 to 7

8+

01

2+

0 to 56 to 12

13+

0 to 34 to 16

17+



FGH

0 to 1415

16+

0 to 34 to 13

14+

0 to 910

11+

01 to 7

8+

0 to 23 to 5

6+


S1S2S3S4S5

KLMNP

0 to 56

7 to 910

11 to 13

14 to 1516 to 1718 to 19

NoneNone

0 to 56

7 to 910

11 to 13

14 to 1516 to 1718 to 19

NoneNone

20+NoneNoneNoneNone

38

2/27/2015

20

39THERAPY REASSESSMENTS

• Therapy reassessments now required only at least every 30 calendar days Effective for episodes beginning January 1, 2015 Applies to each therapy discipline involved

• PT, OT & SLP

30 days reset each time a reassessment occurs Must be performed by qualified therapist

• Assistant visits do not qualify

No longer required prior to 14th & 19th visit

THERAPY REASSESSMENTS

40

2/27/2015

21

Must be performed using objective measurement in accordance with professional standards of clinical practice

Must enable comparison of successive measurements to determine effectiveness of therapy goals

Must document measurement results & effectiveness See archived BKD webinar 2015 Home Health

Medicare Payment & Regulatory Updates – Part II from February 17, 2015


41

Example 1


Description HCPCS Date

PT evaluation G0151 01/01/15

PT assistant G0157 01/03/15














PT reassessment G0151 01/29/15



PT discharge G0151 02/04/15

42

2/27/2015

22

Example 2



PT evaluation G0151 01/01/15

OT evaluation G0152 01/03/15


OT assistant G0158 01/07/15











OT reassessment G0152 02/02/15




PT discharge G0151 02/14/15

43

44PHYSICIAN FTF ENCOUNTERS

2/27/2015

23

• Effective for episodes beginning on & after January 1, 2015 Physician narrative no longer required on FTF

certification However, documentation in physician’s medical

records must justify referral for Medicare HH services• Must support need for skilled services & homebound status

MLN Matters SE1436• http://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNMattersArticles/downloads/SE1436.pdf

PHYSICIAN FTF ENCOUNTERS

45

• Physician FTF encounter certification form Document still required to be signed by physician

prior to claim being billed• Form still needs to include

Date of encounter Indication that encounter was related to primary reason

patient requires HH• Does not need to list specific diagnosis codes

Indication encounter was performed by allowed physician or NPP

Certification that patient is homebound & in need of skilled services


46

2/27/2015

24

• Supporting documentation Certifying physician &/or inpatient physician

medical records shall be used as basis for certification of HH eligibility• Must be sufficient to justify referral to HH &

demonstrate need for skilled services & homebound status Must include actual clinical note used to document FTF

encounter & must indicate encounter• Occurred within required timeframe• Related to primary reason patient requires HH• Was performed by allowed physician or NPP


47

Information from HH offering additional support for skilled need & homebound status can be incorporated into physician’s medical record• Must be corroborated by other medical record entries• Must be signed & dated by physician & incorporated

into physician’s medical record Excerpt from comprehensive assessment, etc.

Expectation continues that HH obtain as much supporting documentation from physician’s medical record to assure HH eligibility criteria are met


48

2/27/2015

25

• Practical process Continue to obtain signed physician FTF encounter

certification form• Form no longer needs physician composed narrative

Continue to obtain additional supporting documentation

• Physician encounter note, inpatient discharge summary, etc.

Provide additional supporting documentation to physician to incorporate into physician’s record

• Excerpt from comprehensive assessment, etc.


49

• Questions & concerns not yet addressed Will intensity level of pre- & post-pay medical review

focused on HH FTF compliance continue? If HH claim is denied for lack of FTF compliance will

physician claim for care plan oversight also be denied?Vice-versa?

If HH provides supporting documentation to physician to incorporate into physician’s record does HH need returned copy from physician to respond to HH pre- or post-payment medical review?


50

2/27/2015

26

51SUMMARY

• 2015 summary New payment rates New transition CBSA codes PPS model changes New therapy reassessment requirements Physician FTF encounter changes

• Clarifications pending

SUMMARY

52

2/27/2015

27

CONTINUING PROFESSIONAL EDUCATION (CPE) CREDITS

BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: www.learningmarket.org.

The information in BKD webinars is presented by BKD professionals, but applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor before acting on any matters covered in these webinars.

53

• CPE credit may be awarded upon verification of participant attendance

• For questions, concerns or comments regarding CPE credit, please email the BKD Learning & Development Department at [email protected]

CPE CREDIT

54

2/27/2015

28

QUESTIONS?

FOR MORE INFORMATION

THANK YOU!M. Aaron Little, CPAManaging [email protected]

2/27/2015

29

2015 HOME HEALTH MEDICARE PAYMENT ... 1 2015 HOME HEALTH MEDICARE PAYMENT & REGULATORY UPDATES –...

Documents

Transcript of 2015 HOME HEALTH MEDICARE PAYMENT ... 1 2015 HOME HEALTH MEDICARE PAYMENT & REGULATORY UPDATES –...