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Change on the Horizon

The 2015 update to  Home Health PPS is considerable and provides for major and minor changes, plus a lot of interesting information.  Here’s the bullet points.

Reduction in Payment

No news here.  Everyone was expecting a decrease in payment.  It comes to approximately $81.00 subtracted from the standard episode rate.  The standard episode rate is that dollar amount which is adjusted by OASIS and other factors to find the final payment rate.  In contrast, the per visit rate has gone up slightly. 

Face to Face documentation requirements

A face-to-face document is still required but the narrative section has been removed effective January 1, 2015.  Within the regulations the effect of the Face-to-Face requirement has been described as follows:

  • The error rate for home health claims was calculated to be 17.5 percent.
  • The majority of home health improper payments were due to “insufficient
    documentation” errors. “Insufficient documentation” errors occur when the medical documentation submitted is inadequate to support payment for the services billed or when a specific documentation element that is required (as described above) is missing. Most “insufficient documentation” errors for home health occurred when the narrative portion of the face-to-face encounter documentation did not sufficiently describe how the clinical findings from the encounter supported the beneficiary’s homebound status and need for skilled services, as
    required by §424.22(a)(1)(v).
    • CMS-1611-F  Page 37

ImportantAll episodes beginning with an OASIS Start of Care assessment will require  Face-to-Face documentation.  While the risk of denial related to the narrative has been reduced, agencies will have far more opportunities to make an error.  This includes patients who return to service after being discharged and patients who were in the hospital over day 60 of an episode and must be readmitted for purposes of billing. 

MD/hospital documentation:  The regulations state that if requested, an agency must cough up the hospital’s documentation if the patient was admitted directly from the hospital or the physician’s notes that demonstrates eligibility.  This should be happening already but from reading clinical records, it is obvious that often the nurses caring for the patient are not reading the hospital documentation.  Do not wait until 2015 to add getting the MD records in the chart prior to billing.

Interesting and Important:  I think the following excerpt is saying that if agencies provide the physician with the information to support eligibility, the physician may use it if he or she signs off on it.   This is in stark contrast to not being able to help the physician compose the narrative.  Read for yourself and feel free offer your own opinion.

The initial assessment visit must be done to determine the immediate care and support needs of the patient and to determine eligibility for the Medicare home health benefit, including homebound status. The Medicare CoPs, at §484.55(b), require a comprehensive assessment to be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care, and for eligibility for the Medicare home health benefit to be determined, including homebound status. We would expect that the findings
from initial assessment and/or comprehensive assessment of the patient would be communicated to the certifying physician.

The certifying physician can incorporate this information into his/her
medical record for the patient and use it to develop the plan of care and to support his/her certification of patient eligibility. The certifying physician must review and sign off on anything incorporated it into his or her medical record for the patient that is used to substantiate the certification/re-certification of patient eligibility for the home health benefit.

End in Sight

Twice in the Federal Regs, there is a directive that all patients whose care extends into a second episode, must be recertified with a documented estimated end in sight for skilled care.  I really thought I missed something in the proposed regs but Lisa Selman-Holman did not see it, either.  Regardless of who saw what, the directive is in place.  Be careful of ‘statutory’ reasons for denial.  This has the potential to be like dates, signatures, etc.  Once it is identified that a recertification did not meet requirements, a full denial can be issued.


There are some changes to the payment calculations.  I am hoping that someone with a better head for math than myself with go through all the numbers and explain to us the difference.  Consider that a cry for help.

Data Submission

There has always been a provision in the Prospective Payment System for a 2 percent penalty for those agencies that did not submit OASIS data.  Nobody knew what that meant.  Did it mean penalties for no data submission or less than 100% data submission?  It has finally been clarified for agencies as 70% of qualifying episodes in 2015 with gradual increases over the next several years. 

Since it is now a requirement for payment that the OASIS data used to determine payment be in the state repository prior to billing, this new definition strikes us as ‘late’ for lack of a better word.  If you are not sure of your data submission status, call us now. You need help.

Value Based Purchasing

Value Based Purchasing is recycled Pay-for-Performance.  The actual indicators that will factor into any payment adjustments have yet to be determined which was common theme in the P4P predecessor.  Although this is not our first rodeo with the concept of Value Based Purchasing, this one may stick.  Keep your ears to the ground for more information.

These regulations run through 259 pages but like most, there is a lot of fluff and stuff inserted between the good stuff.  Take some time and read through the comments and look at some of the data.  We will be doing so as well and posting anything interesting or important we find.

Good luck.  It’s always an adventure when the regulations are changed.


5 Comments Post a comment
  1. Gina #

    Are we to be penalized or denied if the MD records provided to us at the agency does not have specific verbiage? F2F, Home Bound, Reason for skilled services?

    November 3, 2014

    • As I understand it, specific language is not required but the agency will be denied if the records don’t support homebound or need for services. I re-read what I wrote and it’s kind of hazy. It should say that the hospital records are required if the patient is admitted directly from the hospital or the physician records of the patient was not inpatient immediately prior to admission.

      November 3, 2014
  2. Susan Johnsen #

    can you post the page number for the bit on recertification. I missed that first and second time around and want to hunt iit up

    November 3, 2014

    • Susan, I am not at my office and only have my iPad but I am anxious to see what y’all think. In my Kindle app, it is on page 35 but I realize the page numbers may be different and the regs are protected from copying and pasting (I may be able to fix that later). A couple of pages prior to the recertification requirement is a section header that reads, ‘B. Changes to the Face to Face Requirement. It then goes on to state the statutory background. Skip – boring. It then goes on to list the contents of the plan of care – you are getting closer. At the end there is the paragraph about a narrative being required for Management and Evaluation of the Plan of Care. It’s the next paragraph beginning with, ‘when there is a continuous need for.. ..’ Read carefully. Keep going. It’s the third sentence of that paragraph. The sentence has two parts. It is the second part that says something to the effect of, the recertification must indicate the continuing need for skilled services AND estimate how much longer skilled services will be required.

      That is not the only place it is found but again, I am moving between two programs and can’t cut and paste.

      The way it is written makes it seems as though it has always been there and isn’t new. Please read and get back to me and all the readers and let us know if you understand it that way. That applies to anyone who can offer clarification or validation that it says exactly that.

      November 3, 2014

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