PPS Final Rule Makes Some Changes; Not Enough

CMS has issued the final home health payment rule. While the rule includes some modest improvements over the proposed rule, the bottom line is difficult payment cuts to an industry saddled with greater regulatory responsibilities.   Among the major payment changes:

  • CMS withdrew its proposal to eliminate certain hypertension codes from the case-mix scoring model;
  • CMS dropped the application of the 3.79% case-mix weight change adjustment for non-routine supplies;
  • CMS maintained the 3.79% coding weight change adjustment in 2011;   but dropped proposal for an additional 3.79% in 2012. CMS promises to revisit its method of assessing case-mix weight changes prior to any further adjustments,  but the 2012 cut well may resurface as a proposal in the 2012 rate setting.
  • The final rates include a 2.1% market basket index increase — down from the proposed 2.4% — that is reduced under the health care reform legislation by 1 point to 1.1%. (As a result, the base 2011 episodic rate in non-rural areas is $2192.07; $2257.83 in rural areas.)

CMS made some significant changes in the requirements for face-to-face encounters between a patient and his/her physician or non-physician practitioner.  Most importantly, the following changes – suggested in industry comments  – were made:

  • Face-to-face physician encounter timeframe has been extended to 90 days before the start of care or 30 days after the start of care.; an extension on the 30-day/14 day timeline in the proposed rule.
  • Hospitalists will be allowed to perform and document face-to-face visits in certain cases.
  • The overall face-to-face requirement applies to certifications only. (this is a requested clarification)

Additional changes in home health face to face provisions:

CMS allows that hospitalists may perform the encounter, even where a different community-based physician continues care of the patient in home health services and certifies the patient’s care plan. The hospitalist would need to identify the community physician in the discharge plan of home health care.

CMS maintains the documentation requirements but will not hold the HHA responsible for the physician’s documentation. However, CMS does not permit standardized encounter documentation that the physicians or non-physician practitioners simply sign for the HHA.

CMS infers that the face-to-face encounter will not bring any additional physician payment for the services above existing certification payment (G0180) and claims for specific physician services beyond the encounter certification.

HHAs cannot use the Home Health Advance Beneficiary Notice (HHABN) to inform patients that care would not be covered in the event that here is no qualified encounter. CMS does not indicate what kind of notice is authorized, even though this requirement is a condition of payment to an HHA.

Unchanged from the proposed rule – and of great concern –  is the January 1, 2011 effective date. At this stage only Congressional intervention will change this.

In other rule changes:

Agencies will have more flexibility and time to comply with stricter therapy documentation requirements. Specifically:

  • CMS replaces the 13th and 19th visit in an episode proposal with a more flexible approach. A professional therapist assessment in rural areas and non-rural areas under extenuating circumstances (undefined by CMS) must take place any time after the 10th visit but no later than the 13th visit; and after the 16th visit but no later than the 19th visit specific to each discipline of therapy.
  • The assessments required relate only to each therapy discipline individually and not to the combination of therapist services. For example, if a patient has 12 physical therapy visits and 12 occupational therapy visits in an episode, the additional assessments would not be required.
  • CMS does not intend to change longstanding requirements on coverage of maintenance therapy or the development of a maintenance plan of care.
  • CMS maintains its spontaneous improvement limitation on coverage but expresses that a professional therapist should judge whether such is possible with an individual patient.
  • The effective date on assessments is delayed until April 1, 2011.

HH-CAHPS deadlines stay in place. Despite agency concerns about the burden of patient-satisfaction survey requirements in addition to continued OASIS-C implementation, CMS will move forward with plans to withhold agencies’ 2% annual payment update for 2012 if they fail to report data and don’t apply for an exemption.

CMS retains the so-called 36- month rule regarding ownership changes, but with significant exceptions. If there is a change in majority ownership of an HHA by sale (including asset sale or sale of stock, mergers, and consolidations) within 36 months after the effective date of the HHA’s initial enrollment in Medicare or within 36 months of the HHA’s most recent change in majority ownership, the HHA’s provider agreement does not convey to the new owner. The new owner must enroll in Medicare as a new (initial) agency and obtain state survey or accreditation.

The final rule can be accessed electronically at www.ofr.gov/OFRUpload/OFRData/2010-27778_PI.pdf.

Author: Pat Kelleher

Pat Kelleher is Executive Director of the Home Care Alliance of Massachusetts.

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