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CMS Publishes 2014 Home Health Prospective Payment System Final Rule

Thursday, December 19, 2013   (0 Comments)
Posted by: Becky Dryden
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The Centers for Medicare and Medicaid Services (CMS) released its final rule for the Home Health Prospective Payment System for 2014. The final rule affects services provided by home health agencies under Medicare Part A beginning January 1, 2014.

The 2014 final rule reduces Medicare payments under the Home Health Prospective Payment System (HH PPS) by 1.05 percent. This amount reflects the combined effects of an increase in the home health payment update percentage of 2.3 percent, offset by a decrease of 2.7 percent—the result of rebasing the adjustments required by the Affordable Care Act—and a 0.6 percent decrease due to a refinement of the HH PPS Grouper.

As required by the Affordable Care Act, CMS must begin phasing in rebasing adjustments to the national, standardized 60-day episode payment rate, the national per-visit payment rates and the NRS conversion factor to reflect changes since the inception of the HH PPS, such as change in the number of visits in an episode, the mix of services in an episode, the level of intensity of services in an episode, the average cost of providing care per episode, and other relevant factors. Prior to the Affordable Care Act, rates were based on analyses of home health agency cost and service utilization data available in 2000, when the HH PPS originally was implemented.

ICD-9-CM Grouper Refinements, Effective January 1, 2014

As stated in CMS’s proposed rule, CMS clinical staff, along with contractors, completed a thorough review of the ICD-9-CM codes included in the HH PPS Grouper. The HH PPS Grouper, which is used by the CMS OASIS submission system, is the official grouping software of the HH PPS.

As a result of that review, they identified two categories of codes (listed on page 25 of the final rule), made up of 170 ICD-9-CM diagnosis codes, which they proposed to remove from assignment to one of the diagnosis groups within the HH PPS Grouper, effective January 1, 2014. CMS's clinical judgment is that these codes are "too acute," meaning that this condition could not be appropriately cared for in a HH setting or would not impact the Home Health Plan of Care (HH POC), or would result in additional resource use. Therefore, the inclusion of these diagnosis codes in the Grouper was producing inaccurate overpayments. They proposed removal of these codes to ensure greater compliance with ICD-9-CM Coding Guidelines and to assure home health providers are accurately describing the patient characteristics that impact the home health plan of care. In the final rule CMS finalized the rule and will remove the 170 codes starting January 1, 2014.

WOCN expressed concern with the removal of these codes during the open comment period before the rule was finalized. The organization felt that many of the codes that were listed do require sustainable home care and asked for guidance on how to appropriately code these conditions if they are removed.

In response, CMS suggested "…that there are appropriate ICD-9-CM aftercare codes that can be listed on the OASIS assessment to more fully explain the home health care interventions being provided. Stating that those codes should be listed on the OASIS assessment form to best explain the reasons for the home health encounter. The disease states precipitating these services can still be listed on the OASIS assessment, but they are not the primary reason for the home health interventions."

CMS has promised to work with providers to educate them about the changes and provide guidance. They have suggested that providers use the following resources to help comply with the changes:

Quality Reporting

The rule finalizes the addition of two claims-based quality measures: Re-hospitalization During the First 30 Days of a Home Health Stay, and Emergency Department Use Without Hospital Readmission During the First 30 Days of Home Health. In addition, this rule reduces the number of home-health quality measures currently reported to home health agencies to simplify their quality improvement activities. The rule finalizes a policy to continue using Outcome & Assessment Information Set (OASIS) data, claims data, and patient experience of care data to meet the requirement that home health agencies submit data appropriate for the measurement of home health care quality for Annual Payment Update 2014 and each subsequent year thereafter until further notice.

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