Home Health PPS Frequently Asked Questions
SCIC| Consolidated Billing/ Supplies/ DME/ Therapy| Wound Care | RAPS| To and Through
Dates| MSP | Claims Processing |Discharge Rules/ Eligibility| Recertification Window| PEPs |
Payment | Oasis | Diagnosis Coding |Lupa | Hospice |HIPPS Coding | Wage Index | Medical
Review | Cost Reporting | Miscellaneous
SCIC:
Q: How will an agency be paid when the total episode visits are greater than four but there is a
SCIC with fewer than four visits in the pre-SCIC period and/or the post SCIC period?
A: The SCIC adjustment occurs within a given 60-day episode and does not restart the 60 day
episode clock. The LUPA adjustment applies to a total 60-day episode period. As long as the
total SCIC adjusted episode, comprised of both the pre-SCIC and post-SCIC parts, has more than
four visits, the total episode would not be considered a LUPA situation. The LUPA applies to the
total number of visits provided in a given 60-day episode.
We have received may questions on whether the agency is constrained to bill for a SCIC for a
higher HHRG if the net effect is a lower payment for the episode than if the SCIC had not
occurred. Because the intent of the SCIC was not to lower the total episode payment when
patients actually required more intensive services, the HHA is not forced to bill for a SCIC in
this circumstance. However, where the SCIC reflects a lower HHRG due to unanticipated
improvement in patient condition, the SCIC must be billed
Q: Can HCFA reconsider that home health agencies must complete two OASIS assessments
when a SCIC occurs during the last five days of an episode since the only data item that may be
different is MO825-therapy threshold? For example, require two assessments only when it is
known the MO825 will be different on the resumption of care than on the re-certification.
A: At this time, we cannot change the requirement that two discrete OASIS assessments are
required if a SCIC occurs during the last five days of an episode. We will reconsider the issue
with future refinements for year two of PPS.
Q: How will payment be made if a patient experiences a SCIC on a home visit during which the
OASIS is completed, new orders obtained, and treatment initiated? For example: visits are made
on 10/2, 4, 6, 8 under HHRG C1F1S1. On the next scheduled visit on 10/12 a new problem is
found and a new HHRG C1F2S1 is determined, orders received and treatment initiated. Will
payment be deducted for days 9, 10, and 11 when in effect there is no gap?
A: Both parts of the SCIC adjustment are calculated based on billable visit dates. The first part of
the SCIC adjustment reflects the adjustment to the level of payment prior to the significant
change in the patient's condition during the 60-day episode. The first part of the SCIC adjustment
is determined by taking the span of days (the first billable visit date through and including the
last billable visit date) prior to the patient's significant change in condition as proportion of 60
multiplied by the original episode amount. The second part of the SCIC adjustment reflects the
adjustment to the level of payment after to the significant change in the patient's condition during
the 60-day episode. The second part of the SCIC adjustment is determined by taking the span of
days (the first billable visit date through and including the last billable visit date) through the
balance of the 60-day episode, as a proportion of 60.
Q: According to HCFA instructions the SCIC second part proration does not begin until the date
of first billable visit after the OASIS assessment and change in physician's orders have been
completed. Does this mean that if either / or both the OASIS assessment and orders have not
been completed by the 60th day of the episode a SCIC would not apply?
A: As stated in the regulations at 42 CFR 484.205(e) governing the SCIC adjustment, in order to
receive a SCIC adjustment for the significant change in condition that was not envisioned in the
plan of care the HHA must complete an OASIS assessment and obtain the necessary physician
change orders reflecting the significant change in treatment approach in the patient's plan of care.
Both requirements must be completed in order to SCIC adjust the episode.
Q: As per new HIM 11 section 467.27, if therapy use is below the utilization threshold
appropriate to the HIPPS code submitted on the RAP and unchanged on the claim for the
episode, the Pricer software in the claims system will regroup the case-mix for the episode with a
new HIPPS code and pay the episode on the basis of the new code. In a case where the original
OASIS assessment indicated low therapy but due to a change or correction of assessment and
orders there was increased therapy utilization to meet or exceed the therapy threshold, would this
be considered a SCIC or may the HHA place the correct HIPPS code on the claim for proper
payment without changing the original RAP and without rerunning an OASIS assessment
through grouper software?
A: If the patient's need for therapy exceeds the threshold mid episode, the HHA may cancel the
original RAP and resubmit the RAP and claim for the episode reflecting the higher therapy
threshold HHRG code. Conversely, if the patient's actual therapy receipt as reflected on the claim
is lower than the HHRG code reflecting the high therapy group, the systems will automatically
lower the reimbursement level to the lower HHRG category.
Q: What happens when a patient is admitted and 2 days later has had a change in condition?
Does this mean a SCIC is completed?
A: A SCIC could occur in this situation. A SCIC is defined as a significant change in the
patient's condition during a 60-day episode that was not envisioned in the original plan of care.
In order to receive a new case-mix assignment for purposes of payment during the 60-day
episode, the HHA must complete an OASIS assessment and obtain the necessary physician
change orders reflecting the significant change in the treatment approach in the patient's plan of
care.
Q: HCFA should publish a specific clarification stating that PPS does not require a new plan of
care for a SCIC. This would eliminate any confusion that agencies might confront with surveyors
or intermediaries.
A: The SCIC Adjustment is based on appropriate physician verbal orders within a given episode
and does not restart the 60-day episode clock. Your confusion appears to be based on the
regulation text language that is cited in your letter is §409.43(e)(1) which governs review of the
plan of care. Review of the plan of care happens in PEP situations as well as SCIC situations.
This regulation language does not speak to restarting the 60-day episode clock.
In both the preamble and regulation text of the final PPS rule, we provided clarification that the
SCIC payment adjustment policy to provides an opportunity for home health agencies (HHAs)
under PPS to adjust resource levels during a given 60-day episode to account for an
unanticipated change in the patient's condition that requires a change in case mix level. The HHA
must complete an OASIS assessment and obtain the necessary physician change orders reflecting
the significant change in treatment approach in the patient's plan of care. The SCIC adjustment is
the proportional payment adjustment reflecting the time both before and after the patient
experienced a significant change in condition during the 60-day episode.
We believe the following regulation text in the final rule provides the recommended clarification
that the SCIC is based on physician orders and occurs within a given 60-day episode:
§484.205(b)(e) states, "Significant change in condition adjustment. The HHA receives a national
60-day episode payment of a predetermined rate for home health services paid on a reasonable
cost basis as of August 5, 1997, unless HCFA determines an intervening event defined as a
beneficiary experiencing a significant change in condition during a 60 day episode that was not
envisioned in the original plan of care occurred. In order to receive a new case-mix assignment
for purposes of payment during the 60 day episode, [emphasis added] the HHA must complete
an OASIS assessment and obtain the necessary physician change orders reflecting the
significant change in treatment approach in the patient's plan of care [emphasis added]. The
total adjustment is a proportional payment adjustment reflecting the time both prior and after the
patient experienced a significant change in condition during the 60-day episode [emphasis
added]. A SCIC adjustment is determined in accordance with § 484.237.
Q: How do you pronounce the SCIC achronymn?
A: The achronymn is pronounced "SICK" Adjustment not "SKICK" Adjustment.
Q: Why are payments under a SCIC adjustment thru the last visit instead of the end of episode?
A: As set forth in the proposed rule and final rule governing home health PPS the SCIC
adjustment is calculated based on billable visit dates. We believe the calculation is an equitable
approach to ensure that resources reflect the time care is provided by the HHA. Because the
intent of the SCIC was not to lower the total episode payment when patients actually required
more intensive services, the HHA is not forced to bill for a SCIC in this circumstance. However,
where the SCIC reflects a lower HHRG due to unanticipated improvement in the patient
condition, the SCIC must be billed.
Q: If I expect to do 9 therapy visits at start of care, it is my understanding that if I do 10 therapy
visits (one more than expected) that I must prepare a SCIC adjustment. It that true?
A: If the therapy threshold MO825 is the only case mix item that requires adjustment due the
patient's condition, the HHA has the option to cancel and resubmit a RAP or SCIC, as
appropriate, to adjust the episode. The determination of whether a the resubmission of a RAP or
a SCIC is appropriate is dependent upon whether the additional therapy services was a result of a
significant change in the patient's condition. The intermediary system will not automatically
upgrade a non-therapy HHRG to a therapy HHRG when the final claim indicates 10 or more
therapy visits.
Instructions for correcting the MO825 item on the OASIS are outlined in the OASIS program
memorandum (in page 29) that can be accessed on our web site at
http://www.hcfa.gov/medicaid/oasis/hhregs.htm and scrolling down to the item labeled OASIS
program memorandum. We suggest printing the file labeled 99-2.65 dated 11/17/99 for this
information.
Q: It was stated that an agency can have an unlimited amount of SCICs, but you would only be
reimbursed for six SCICs in a given episode. Is it true?
A: HCFA systems can only process up to six SCIC adjustments for a given home health
beneficiary in a 60 day episode. Although highly unlikely, a beneficiary may experience more
than six significant changes in condition during a given 60-day episode that constitute a SCIC
adjustment. That situation would require manual intervention.
Q: A patient has been discharged from an agency with goals met and is hospitalized after
discharge with an exacerbation of the same condition. The patient is discharged from the hospital
to the same home health agency. What type of adjustment would apply?
A: We are assuming that this scenario takes place during a 60 day episode period. The PEP
adjustment for the discharge and return to the same HHA during the 60-day episode period is
only recognized when a beneficiary reached the treatment goals in the original plan of care. The
original plan of care must be terminated with no anticipated need for additional home health
services for the balance of the 60-day episode period. The discharge cannot be a result of a
significant change in condition. If the patient in this scenario was truly discharged with goals met
and no anticipated need for additional home health services, the HHA would receive a PEP
adjustment in this situation. The original 60 day episode would be proportionally adjusted and
the new 60 day episode clock would begin upon return. However, we believe this would be a
rare occurrence. A pattern of discharge, hospitalizations for an exacerbation of the original
condition and the subsequent need for home health care in the same 60 day episode could raise
program integrity concerns.
Q: What is HCFA's exact definition of SCIC? Must you have a physician change orders to start a
new HHRG?
A: As defined in the final home health PPS rule published in the Federal Register on July 3,
2000. The SCIC adjustment occurs when a beneficiary experiences a significant change in
condition during a 60-day episode that was not envisioned in the original plan of care. In order to
receive a new case mix assignment for purposes of payment during the 60-day episode, the HHA
must complete an OASIS assessment and obtain the necessary change orders reflecting the
significant change in the treatment approach in the patient's plan of care. The total significant
change in condition payment adjustment is a proportional payment reflecting both the time prior
and after the patient experienced a significant change in condition during the 60-day episode. As
stated above, the HHA must obtain physician change orders in order to SCIC adjust the episode.
Q: Please clarify the SCIC adjustment refinement policy. Are providers going to be punished for
improving patients and, therefore, creating lower pricer scores?
A: We have received may questions on whether the agency is constrained to bill for a SCIC for a
higher HHRG if the net effect is a lower payment for the episode than if the SCIC had not
occurred. Because the intent of the SCIC was not to lower the total episode payment when
patients actually required more intensive services, the HHA is not forced to bill for a SCIC in
this circumstance. However, where the SCIC reflects a lower HHRG due to unanticipated
improvement in patient condition, the SCIC must be billed. The SCIC improvement does not
apply to patient improvement that reflects the goal of patient improvement in the plan of care.
The SCIC adjustment requirement applies to unanticipated improvement during the course of the
60-day episode.
Q: A home health agency has a patient who is discharged from the hospital in the last 5 days of a
485. This patient would constitute a SCIC. Does the HHA have to do two 485s, one for the date
it resumes care to the end of the 485 certification period, and a new one for the next certification
period? If the patient goes back into the hospital in the last 5 days of the certification period,
does the HHA do one 485, for the present certification period only, or two, one each for the
present period and the new certification period?
A: The SCIC only requires a verbal order to be written and signed by the physician. A new 485
would not be required for the first episode in this example. A new 485 would be written for the
second episode in this example.
Consolidated Billing / Supplies / DME/ Therapy:
Q: Is a one time nursing visit now allowable if the patient is under a qualifying POC for PT?
A: The nursing visit would only be allowed if ordered by the physician in the patient's plan of
care and was medically necessary.
Q: Are nurse practitioner visits made to patients' homes as part of a physician office practice part
of the bundled PPS episode payment to home health agencies? Are home visits made by nurse
practitioners on behalf of a physician directed wound care center part of the bundled PPS episode
payment to home health agencies?
A: As you are aware, there are a vast array of entities that are called "wound care centers." A
"wound care center" is not specifically recognized in the Medicare law as a Medicare
participating provider. Nurse practitioner services that are bundled into the physician fee
schedule payments are not recognized as a home health service included in the PPS rate.
Q: If a patient is receiving outpatient therapy services while receiving home health services, what
is the billing process for these patients? Is this included in the PPS payment and it is our
responsibility to pay the appropriate entities involved?
A: For beneficiaries under a home health plan of care, the HHA is responsible for providing all
covered home health services either directly or under arrangement during an open episode. If an
HHA contracted with an outpatient hospital department to provide physical therapy under
arrangement on their behalf, the HHA would bill for the episode and reimburse the entity
providing the physical therapy on their behalf. The entity that provided physical therapy under
arrangement on behalf of the HHA cannot bill Medicare directly for the services while the
patient is under a home health plan of care.
Q: When a patient is discharged from an agency for goals met and goes to outpatient therapy
(CORF) within the 60 day, what type of reimbursement does the agency receive? Or the agency
is responsible to reimburse the outpatient service?
A: It is difficult to envision this scenario in which a Medicare patient eligible for home health
services continues to need therapy during a 60-day episode, but has been discharged with goals
met. If this is a possible situation and there is a subsequent need for therapy after discharge, then
unless the patient becomes subsequently eligible for home health before the end of the 60 day
episode the HHA would receive a full 60-day episode payment without reimbursing the
outpatient department.
Q: As I understand the PPS regulations, if a HHA only offers skilled nursing service and HHA
service and has a client on these services; the Client goes to the hospital and now needs PT
service. As I understand the regulations, the HHA is obligated to take the patient back - but does
not offer PT service so this HHA has to provide PT service through a Medicare approved entity.
This could be through a contractual agreement with another HHA only, because if they
contracted with another entity i.e. hospital or OPT, the HHA would then be offering the service
through an agreement and would have to meet the HCFA regulation that deals with required
information needed in a contract. But, the HHA does not want to offer PT service or cannot offer
these services because there are no PT's, OT's, MSW's, etc. in the service area. Is HCFA now
forcing HHA's to offer all services?
A: Under the PPS system a single provider is paid in full for all home health services a patient
needs during a discrete 60-day episode of care. Thus, if the provider does not have the resources
to furnish these itself, it must contract for the services if it is unable to provide the services a
patient requires.
As discussed in our response to Question #1 of this document, on page 41162 of the preamble of
the final home health PPS rule published on July 3, 2000 in the Federal Register, we believe that
HHAs should be given the option to discharge the patient within the scope of its own operating
policies; however, an HHA discharging a patient as a result of hospital [SNF or rehab facility]
admission during the 60 day episode will not be recognized by Medicare as a discharge for
billing and payment purposes. An intervening hospital [SNF or rehab facility] stay will result in
either an applicable SCIC adjustment or, if the resumption of care OASIS assessment upon
return to home health does not indicate a change in case-mix level, a full 60 day episode will be
provided spanning the start of care date prior to the hospital [SNF or rehab facility] admission,
through and including the days of the hospital admission, and ending 59 days after the original
start of care date. If the HHA has discharged the patient and billed the claim for the patient and
does not cancel the claim and re-bill for the episode when the patient returns from the inpatient
stay, then Medicare systems will PEP the prior episode and start a new 60 day episode clock.
Failure to cancel the claim and re-bill in this situation may financially disadvantage the HHA.
There are pending clarifications to the billing instructions.
Q: Is a HHA agency responsible for whirlpool services performed at an outpatient center if the
patient is being treated under a home health plan of care? Likewise, what responsibility would a
HHA have for services received by a patient who also attends Medical Day Care for medical
treatment?
A: The HHA is responsible for providing all covered home health services except DME either
directly during the patient's 60-day episode. Therapy that meets coverage guidelines provided at
an outpatient center would be subject to the consolidated billing requirements. Medical day care
is not a category of services covered by Medicare.
Q: A patient is being seen under a home health plan of care. The ordered services are nursing,
physical therapy and home health aide. After two weeks, it is determined that the patient needs to
be seen in an outpatient therapy clinic due to the need of specialized equipment. Can the
outpatient clinic bill for these services or must the outpatient clinic bill the HHA?
A: The law is specifies that all home health services (except durable medical equipment) listed in
section 1861(m) of the Social Security Act are subject to the consolidated billing requirements
and, therefore, bundled to the HHA while the patient is under a home health plan of care.
Therapy services are included both in the PPS rates and subject to the consolidated billing
requirements governing PPS. The outpatient clinic cannot bill Medicare directly for physical
therapy, occupational therapy or speech-language pathology services while the patient is under a
home health plan of care. The clinic may provide the therapy under arrangement on behalf of the
HHA. The clinic would look to the HHA for payment.
Q: We just heard that if we contract with a wound center they will be treated like contract staff
and we will be responsible for verifying licensure, skills, background etc. Is that true?
A: The HHA is responsible for the services provided under arrangement on their behalf by other
entities. Covered home health services at section 1861(m) of the Act (except DME) are included
in the base line PPS rates and subject to the consolidated billing requirements while the patient is
under a plan of care of the HHA. The time the services are bundled is while the patient is under a
home health plan of care. As you are aware, there are a vast array of entities that are called
"wound care centers." A "wound care center" is not specifically recognized in the Medicare law
as a participating provider.
Physician services or nurse practitioner services that are bundled into the physician fee schedule
payments are not recognized as a home health service included in the PPS rate. Supplies incident
to a physician service or related to a physician service billed to the Carrier are not subject to the
consolidated billing requirements. The physician would not be acting as a supplier billing the
DMERC in this situation-- the physician, nurse or therapist cannot act as a supplier and bill the
DMERC for one of the 178 HCPCs codes listed in the final rule or any other routine or
nonroutine medical supply used in the course of the patient's home health plan of care during an
open episode. Those supplies are bundled into the rate and subject to the consolidated billing
requirements.
Routine and non-routine medical supplies are subject to the consolidated billing requirements
while the patient is under a plan of care during an open episode under PPS. The list of 178 codes
provided in the final rule reflects those medical supply codes that have a duplicate Part B code
that could have been unbundled prior to PPS-but cannot be separately billed under PPS and are
subject to the consolidated billing requirements governing PPS. The 178 list is not an all
inclusive list because there are routine and non-routine medical supplies that do not have a
duplicate code.
Therapies (PT,OT &Speech) are covered home health services that are included in the base line
rates and subject to the consolidated billing requirements. In addition to therapies that had been
paid on a cost basis under home health, we have included in the final rates additional amounts for
Part B therapies that could have been unbundled prior to PPS-these therapies are subject to the
consolidated billing requirements. There are 17 revenue center codes that reflect the ranges of
outpatient the PT,OT, and Speech-language Pathology Services and 54 HCPCs codes that reflect
physician supplier codes that are PT, SP, and OT by definition of the code that are subject to the
consolidated billing requirements and therefore cannot be separately billed to Part B while a
patient is under a home health plan of care during an open episode. A therapist providing
services on behalf of the wound care center could not bill Medicare directly using one of those
therapy codes. The medical supply issue is the same for therapist at a wound care center. Let me
reiterate that medical supplies are bundled into the rate and subject to the consolidated billing
requirements while the patient is under a home health plan of care. The list of 178 codes
provided in the final rule reflects those medical supply codes that have a duplicate Part B code
that could have been unbundled prior to PPS-but cannot be separately billed under PPS and are
subject to the consolidated billing requirements governing PPS. The 178 list is not an all
inclusive list because there are routine and non-routine medical supplies that do not have a
duplicate code.
Q: What are HHA's responsibilities related to outpatient services provided by hospitals, SNFs,
and rehab facilities and included on the home health claim as part of consolidated billing? Must
HHAs ensure that the providers at these sites meet the home health CoPs? Is the HHA
responsible for clinical decision making and quality of care issues for these providers? Must
HHAs ensure that the services meet all coverage criteria for outpatient B therapy? Will the HHA
be held accountable for denials of coverage for services delivered by outpatient therapy
providers on the HHPPS claim?
A: Yes, HHAs must ensure that hospitals, SNFs, and rehab facilities who provide outpatient
services included on the home health claim as part of consolidated billing furnish services
consistent with the home health conditions of participation. The HHA is responsible for clinical
decision making and quality of care issues for the services furnished or home health services by
these providers. HHAs must ensure that the services meet all home health coverage criteria for
therapy. The HHA will be held accountable for denials of coverage for services delivered as
home health services by outpatient therapy providers on the HHPPS claim.
Q: How should a rehab provider handle the following situation? In personal care homes or
assisted living facilities you will find rehab providers who lease space and provide outpatient
(Medicare B) physical therapy, occupational therapy and speech-language pathology services to
Medicare beneficiaries. These same Medicare beneficiaries are receiving home health nursing.
The patient is truly homebound, but the onsite arrangement leads to the beneficiary choosing
outpatient therapy services and home health nursing services. How will this fare when in home
health the OASIS and HHRG dictates a need for home health rehab services?
A: While the patient is receiving services from the home health agency and is under a home
health a plan of care, the home health agency must provide the therapy services either directly or
under arrangement. The rehab provider may provide the services under arrangement to the home
health agency and will seek reimbursement from the home health agency, as the home health
agency will receive the payment for the episode. There may be issues of duplicative sources for
beneficiaries who reside in personal care homes or assisted living facilities. Please check the
specific state law(s) and the base contract that the beneficiary is provided with when he or she
enters an assisted living facility.
Q: The final regulations indicate that payments for services at hospitals, SNFs and rehabilitation
centers when they include equipment too cumbersome to bring to the home have been
incorporated into the baseline cost data and the HHA must now provide these services either
directly or under arrangement. Please provide a comprehensive listing of these services for which
the HHA would be responsible.
A: Section 1861(m) of the Social Security Act defines home health services, which include
services that require equipment that is too cumbersome to bring into the home. These services
were previously billed as therapy visits under the home health benefit and would have a revenue
code of PT. Therefore, they are bundled into the PPS rate and are subject to consolidated billing.
Q: Can I get a list of the codes that were used to identify the "therapy" services previously
unbundled and paid under Part B that will now be bundled into the episode rate under HH PPS?
A: Yes. If you go HCFA's WEB site at http://www.hcfa.gov/stats/pufiles.htm and scroll down to
the Home Health Prospective Payment System section, you can download the 54 HCPCs used
identify the therapy services under Part B physician/supplier claims. HCFA also used the
following revenue center codes to identify therapy services under the Part B Outpatient benefit:
0421 through 0424, 0430 through 0434, 0439, 0440 through 0444, and 0449
Q: Are home health agencies required to provide all adult diapers and underpads used by a
patient while under a home health plan of care? Is payment bundled into the PPS episode rate? If
so, is the requirement to provide diapers limited to current coverage criteria related to diapers?
A: Coverage of adult diapers and underpads are limited to current coverage criteria which limits
coverage to the core items furnished as part of the agency's care. The PPS baseline reflects the
limited coverage of adult diapers and underpads.
Q: Are home health agencies required to provide all diabetic supplies (insulin syringes,
platforms, lancets, blood gluctose strips) used by a patient while under a home health plan of
care? Is payment bundled into the PPS episode rate?
A: All non-routine medical supplies are bundled into the episode rate and subject to the
consolidated billing requirements for eligible beneficiaries under a home health plan of care
during an open episode. Durable medical equipment (DME) is paid separately from the PPS rates
and is excluded from the consolidated billing requirements governing PPS. The determining
factor is the medical classification of the supply, not the diagnosis of the patient. Some of the
supplies mentioned in your question may be considered non-routine medical supplies that are
included in the PPS rate and subject to the consolidated billing. Other diabetic supplies listed in
your question are defined as DME (e.g., A4253 blood glucose/reagent strips, A4258 lancet
device) and are therefore paid separately from the PPS rate and are not subject to the
consolidated billing.
Q: Are home health agencies required to provide all medical supplies associated with IV
infusions (tubing, IV site dressings, IV catheters) used by the patient while the patient is under a
home health plan of care? Is the payment bundled into the PPS episode rate?
A: As stated above, all non-routine medical supplies are bundled into the episode rate and subject
to the consolidated billing requirements for eligible beneficiaries under a home health plan of
care during an open episode. DME is paid separately from the PPS rates and is excluded from the
consolidated billing requirements governing PPS. The determining factor is the medical
classification of the supply, not the diagnosis of the patient. Infusion therapy will continue to be
covered under the DME benefit separately paid from the PPS rate and excluded from the
consolidated billing requirements governing PPS. The DME supplies that are currently covered
and paid as part of the DME benefit on the DME fee schedule as category SU can only be billed
separately when the DME the supply is used for is used by the patient in the home.
Q: The final regulations indicate that payments for services at hospitals, SNFs and rehabilitation
centers when they include equipment too cumbersome to bring to the home have been
incorporated into the baseline cost data and the HHA must now provide these services either
directly or under arrangement. There is no description in the 7/3/00 FR describing the cost addon for these services. How were these costs included into the national PPS rate?
A: Section 1861(m) of the Social Security Act defines the services covered under the Medicare
home health benefit. Section 1861(m)(7)(A) includes services provided at hospitals, skilled
nursing facilities or rehabilitation centers that involves the use of equipment that cannot be made
available to the patient in his/her place of residence. These services were billed as covered home
health services prior to PPS and are included in the baseline calculations of the PPS rates. There
is no separate add-on.
Q: If a patient is admitted for a condition which is not related to an ostomy, but has an ostomy, is
the HHA required to provide the ostomy supplies?
A: The law is specific to the type of items and services bundled to the HHA and the time the
services are bundled. Medical supplies are bundled while the patient is under a home health plan
of care.
Q: There are references to 178 (corrected to 175 (HIM 11 still indicates 178)) non-routine
medical supplies unbundled in the past but now included in PPS payment rates. Is this listing allinclusive within the definition of non-routine supplies or are there other non-routine supplies for
which home health agencies will be responsible? If there are others, will there be a further update
to HIM 11 section 204.1,to define or provide a complete comprehensive listing of all non-routine
supplies?
A: The list of 178 codes provided in the final rule reflects those medical supply codes that have a
duplicate Part B code that could have been unbundled prior to PPS. The 178 list is not an all
inclusive list because there are routine and non-routine medical supplies that do not have a
duplicate code. We are planning to provide on our web site a list of all DME, prosthetics and
orthotics that are not subject to the consolidated billing requirements.
Q: Do we reimburse patients for supplies they purchase that should have been covered under the
PPS payment for that episode? (Example: patient using AARP for ostomy supplies)
A: The patient is free to pay out of pocket for supplies, however, the HHA must make suitable
medical supplies available to beneficiaries.
Q: If patient has primary or secondary diagnoses of diabetes, is the agency responsible for all
supplies related to diabetes?
A: All routine and non-routine medical supplies are bundled while the patient is under a home
health plan of care. However, DME including DME covered supplies are not subject to the
consolidated billing requirements. It is important to note that many diabetics utilize DME and
DME supplies for whom the DME is separately billable.
Q: Is the agency responsible for the incontinent supplies during the 60 day episode even after pt
has been discharged sooner than 60 days for goals met?
A: Once the patient is discharged from home health and not under a home health plan of care, the
HHA is not responsible for medical supplies.
Q: Scenario: A patient has been receiving ostomy supplies for years from a Part B vendor. On
November 2nd, a 30-day supply is shipped to the patient. The vendor has proof of receipt by the
patient. The patient requires home health services beginning on November 10 and ending
November 24.
A) Assuming the Part B supplier sends a bill to Medicare on November 7, will the HHA be
financially responsible for payment of any of these supplies? If so, how many days worth of
supplies would the HHA be responsible to pay?
B) Assuming the Part B supplier sends a bill to Medicare on or after November 10, does your
answer to the first question change?
C) Assume a 30-day supply order is placed on November 15 and received by the patient on
November 20. What financial obligation does the HHA have (the entire order, supplies used
from 11/20-11/24 only, other)?
A: HCFA systems will be editing against the "From" and "To" dates on the Part B Supplier
Claims. As long as those dates do not overlap the episode start date, then the HHA will not be
responsible for those supplies.
Q: In a conference call HCFA stated that while diapers/chux did need to be covered, the agency
need only supply the diaper for agency staff to use while they were in the home. The HCFA
representative went on to say that agencies were not responsible for those diapers while agency
staff were not in the home. Is this true?
A: The national policy governing diaper coverage has not changed with home health PPS.
Diapers have been covered for use in the normal course of the visit. For example, a patient is
bathed during the course of a visit and needs a replacement diaper.
Q: An RHHI stated agencies are responsible for diapers for patients throughout the entire
episode. We think we are responsible for diapers used during a visit. Which is correct?
A: As stated above, the coverage policy governing diaper use is during the course of the visit.
Throughout the episode, the agency is responsible for diapers during the course of visits.
Q: Are diapers included in the episodic payment?
A: Yes. Medical supplies are included in the baseline rates under home health PPS.
Q: If the agency is responsible for diapers used only during the actual visit, what rule changes to
make us responsible for other supplies used by the patient outside of the actual visit?
A: The law requires all medical supplies (routine and non-routine) bundled to the agency while
the patient is under a home health plan of care. The primary agency is the only entity that can bill
and receive payment for medical supplies during an episode for a patient under a home health
plan of care. Both routine and non-routine medical supplies are included in the base rates for
every Medicare home health patient regardless of whether or not the patient requires medical
supplies during the episode. Due to the consolidated billing requirements, we provided additional
amounts in the base rates for those non-routine medical supplies that have a duplicate Part B
code that could have been unbundled to Part B prior to PPS. Diapers are covered in a similar
manner as a towel or other routine medical supplies used in the normal course of the visit. A
routine medical supply would not be provided for the use of the beneficiary between visits in the
same manner as a non-routine medical supply.
Q: Are insulin syringes excluded from the bundled requirement as lancets and test strips are?
A: No, insulin syringes are bundled. Lancets and test strips are excluded, not bundled, because
they are considered incident to blood glucose monitors, which are DME.
Q: After Oct. 1, 2000, a client is on service with a Medicare certified HHA under a 60-day plan
of treatment (POT). On day 30 of this POT, a shipment arrives at the home of the client from a
medical supply company. Supplies included are items covered under the PPS POT. The HHA did
not order these supplies and had no knowledge of this order. Who is responsible for the bill?
A: We need to know when the supplies were ordered. If they were ordered prior to the patient's
start of care date then, as long as the supplies are covered by Medicare and are reasonable and
necessary, Medicare would pay for them. If the supplies covered under the PPS POT were
ordered for the period the patient is under a home health plan of care, then our system edits
would prevent payment by Medicare to the medical supply company. In the latter case the HHA
is not responsible for the bill since it did not arrange for the supplies.
Q: What diabetic supplies are included in the bundled amount?
A: Please refer to the following web address: http://www.hcfa.gov/stats/pufiles.htm#hhapps for a
list of the 178 procedure codes identified as non-routine medical supply codes that were
previously unbundled and billed under Part B prior to HH PPS. These codes are now bundled
into the HH PPS rate. The 178 list is not an all-inclusive list because there are routine and nonroutine medical supplies that do not have a duplicate code. Refer to
http://www.hcfa.gov/medicare/dmecdesc.xls for a list of DMEPOS codes that can be billed
separately (unbundled).
Q: Please discuss/explain the unbundling of diabetic patient supplies.
A: All non-routine medical supplies are bundled into the episode rate and subject to the
consolidated billing requirements for eligible beneficiaries under a home health plan of care
during an open episode. Durable medical equipment (DME) is paid separately
from the PPS rates and is excluded from the consolidated billing requirements governing PPS.
The determining factor is the medical classification of the supply, not the diagnosis of the
patient. Some diabetic supplies may be considered non-routine medical supplies that are included
in the PPS rate and subject to the consolidated billing. Other diabetic supplies may be are defined
as DME (e.g., A4253 blood glucose/reagent strips, A4258 lancet device) and are therefore paid
separately from the PPS rate and are not subject to the consolidated billing.
The list of 178 codes provided in the final rule reflects those medical supply codes that have a
duplicate Part B code that could have been unbundled prior to PPS. The 178 list is not an allinclusive list because there are routine and non-routine medical supplies that do not have a
duplicate code. On our web site, we have provided a list of all DME, prosthetics and orthotics
that are not subject to the consolidated billing requirements.
Q: Can a billing for osteoporosis drugs appear on a PPS claim?
A: Yes. Our billing instructions say that the osteoporosis drug should be billed under revenue
code 636 with a specific HCPC for the drug-- J0630-- this code is defined as up to 400 units.
Q: If we discharge a wound care patient, can we order supplies from a DME company on the
same day? What if the patient is reopened within 60-day period, who is then responsible for
supplies?
A: You cannot order supplies on the same day as the discharge. The HHA must first close the
episode by submitting a final claim and the final claim must be processed in order for a supplier
to be able to bill, effective with the day after discharge. If the patient's plan of care goals are met
and the patient is discharged and then re-admitted within the same 60-day period, this would
result in a PEP for the 1st episode. The HHA would be responsible for the supplies during the 2nd
episode as well.
Q: How will medical supply costs be included into the outlier payment and at what rate? Part B
allowable?
A: Medical supply costs are not used in the calculation of the outlier payment.
Q: Will there be a consideration for "relief" from HCFA with providing the tremendous amount
of "supplies" to our clients - even those supplies that are not related to the patients' episode/plan
of care?
A: Although we appreciate the concern raised by your question, the law does not provide for
such "relief". We would point out that the full cost of supplies has been incorporated into the
PPS rate structure and that higher cost supplies used by some patients will be offset by patients
using little or no supplies.
Q: Please clarify, if wound center goes ahead and bills Part B for supplies for patient already
under HH POC, will the wound center get a denial? For those Part B supplies?
A: Routine and non-routine medical supplies are subject to the consolidated billing requirements
while the patient is under a plan of care during an open episode under PPS.
The list of 178 codes provided in the final rule reflects those medical supply codes that have a
duplicate Part B code that could have been unbundled prior to PPS-but cannot be separately
billed under PPS and are subject to the consolidated billing requirements governing PPS. The
178 list is not an all-inclusive list because there are routine and non-routine medical supplies that
do not have a duplicate code. Part B supplies incident to a physician's care and billed to the
carrier are not bundled; supplies billed to the DMERC are bundled in the same way as in supplier
billing.
Q: If a patient has multiple payer sources (i.e. Medicare for skilled - Medicaid waiver), supplies
always paid by Medicaid - must they be transferred to Medicare. Patient has Medicare insurance.
Insurance doesn't consider q mb catheterization as skilled but has always paid for supplies. Must
they be transferred to Medicare?
A: Yes, assuming these are medically necessary non-routine supplies.
Q: If a patient is under a POC and the doctor's office sees the patient in his office and changes
the wound dressing, how does that doctor bill supplies? Can he/she bill Medicare or does the
HHA have to pay?
A: These supplies are incident to the physician's services and are not bundled into the HH PPS
rate. He/she can bill Medicare Part B.
Q: A hospital - HCFA approved provider based wound clinic performs services/supplies to a HH
patient. Is the HHA responsible for those costs? Answer Yes or no.
A: The HHA is responsible if the home health services and supplies are provided by the wound
clinic under arrangement to the HHA.
Q: Is it true that if a patient purchases supplies from a DME vendor that your agency does not
have a contract with that the agency is not responsible for the payment to the DME (assuming
you have notified the patient)?
A: A patient has the option to purchase supplies out-of-pocket from any vendor they choose.
However, if Medicare is going to pay for it, the patient must accept the covered supplies from the
HHA that it has elected to receive care from. This would mean, in turn, that the patient accepts
the supplies from the vendor(s) that the HHA has a contract or agreement with. So you are
correct, assuming the HHA made it very clear to the patient, the HHA would not be responsible
for payment to a vendor that it does not have an agreement with.
Q: Please clarify the corrections made to the list of Part B codes that could have been unbundled
to Part B prior to home health PPS, but are subject to the consolidated billing requirements under
home health PPS.
A: On our website, we have provided corrections to the final rule. There were 180 codes
published in the final rule. Three of the 180 codes were erroneously listed. The three erroneous
codes are K0137, K0138 & K0139. Subtracting those three erroneous codes yields a subtotal of
177 codes. In addition, one erroneous code (A4454 tape all sizes) was included in the original list
of 180 codes due to a transposition of numbers. The correct code due to the original transposition
is A4554 underpads. The subtotal is still 177 codes. We added (A6248 hydrogel drg gel filler).
The code total is 178. There is an existing process that governs the deletion, discontinuation,
replacement, and addition of new codes that may affect the list published in the Federal Register.
The list of codes in the Federal Register, with the correction described above, was used to
identify the costs of those items as they were coded in 1998. Since the time these codes were
used in rate development some of these codes have been converted through the existing coding
process. Thus these codes, in themselves, do not constitute an inclusive or unchanging universe
of bundled codes.
Q: The list of Part B medical supplies subject to consolidated billing includes "incontinence
supplies." How does HCFA define "incontinence supplies?" What specific products/items are
included under this code, and where can HHAs find the coverage criteria and limitations?
A: The code for "incontinence supplies" that you refer to is A4335. A4335 is a miscellaneous
code that would include a urinary type device that did not match any of the existing codes. It did
not have a high enough volume for its own code. The national policy governing diaper coverage
has not changed with home health PPS. Diapers have been covered for use in the normal course
of the visit. For example, a patient is bathed during the course of a visit and needs a replacement
diaper.
Q: Please advise us on the responsibility of HHAs to provide medical supplies, other than those
"needed to treat the illness or injury that occasioned the home health care" (42 CFR 409.44(f)),
to home health patients who do not have Medicare B coverage. The PPS baseline does not reflect
non-home health medical supplies needed and used by beneficiaries who do not have Medicare B
coverage. Therefore, requiring HHAs to provide these supplies as part of the bundled PPS
payment rate will result in insufficient payment and expand the scope of the Medicare B benefit
to individuals who are not entitled to those Medicare payment supplies. In addition, inclusion of
such a requirement fails to fulfill the purpose of consolidated billing as part of HHPPS, that is the
prevention of duplicate claims to Medicare.
A: There is a difference between providing supplies that are needed in the course of a visit but
which otherwise would not have been covered under the home health benefit or Part B and
supplies that are "needed to treat the illness or injury that occasioned the home health care."
For instance, typical non-home health medical supplies are diapers which are often required to be
provided in the course of a home health visit when the visit includes or requires the patient to
take a bath; but otherwise, a diaper would not be provided. Medical supplies that are needed to
treat the patient's illness(es) or injury are bundled into the rate and subject to consolidated
billing. The law does not differentiate under the home health benefit between patients eligible
under Part A or Part B.
Q: Since DME and medical suppliers do not have access to the common working file, how will
they know when a beneficiary is under the care of a home health agency? Will the supplier be
denied payment as a result?
A: The DME and medical suppliers will have to rely on the beneficiary, the beneficiary's
physician, and the beneficiary's informal (family) caregivers to provide them with this
information. The supplier will be denied payment for supplies provided to the patient if the
patient is under a plan of care at that time. If it is subsequently determined that supplies were
furnished after the period of the home health episode, the supplier can resubmit the claim for
payment.
Q: Home health agencies will provide and bill for routine and non-routine medical supplies but
what about durable medical equipment?
A: The Balanced Budget Refinement Act of 1999 excluded durable medical equipment from the
consolidated billing requirements of home health prospective payment. Home health agencies are
not required to provide durable medical equipment nor are they required to bill for it. A home
care patient may obtain durable medical equipment from whichever supplier he/she chooses,
regardless of the patient's home health agency's contracted supply relationship(s). For purposes
of clarification, the following HCPCS codes are durable medical equipment and may be provided
by and billed by the durable medical equipment supplier: E0607 Home blood glucose monitor,
E0609 Blood glucose monitor with special features, A4244 Alcohol or peroxide, per pint, A4245
Alcohol wipes, per box, A4246 Betadine or pHisoHex solution per pint, A4247 Betadine or
iodine swabs/wipes, per box, A4250 Urine test or reagent strips for home blood glucose monitor,
per 50 strips, A4254 Replacement battery, any type, for use with medically necessary home
glucose monitor owned by patient, each, A4255 Platforms for home blood glucose monitor, 50
per box, A4256 Normal, low and high calibrator solution/chips, A4258 Spring-powered device
for lancet, each, and A4259 Lancets, per box of 100. Items A4244 through A4247, A4259,
A4253, A4256, and A4258 are covered for patients for whom the glucose monitor is covered.
Q: I am still confused regarding the responsibilities of the home health agency to provide
medical supplies.
Here is my example - A quadriplegic who performs intermittent catheterization 6 times/day.
He/she develops a decubitus ulcer which requires home health services for wound care. Under
PPS, I understand the wound supplies would be included in the PPS episodic rate. What about
the catheter supplies that are unrelated to the home health agency "plan of care" i.e. wound care?
A: The law is specific at Section 1895(b)(1) of the Social Security Act about what is included in
the new payment rate. All services covered and paid on a reasonable cost basis as of the date of
enactment of the BBA, including medical supplies, are to be paid on the basis of a prospective
payment amount under HHA PPS. The statutory language specifically refers to the inclusion of
medical supplies in the prospective payment rate. We believe the statute requires the inclusion of
costs of non-routine medical supplies in the episode rate. Furthermore, the law is specific at
Section 1842(b)(6)(F) of the Act, as amended by section 305 of the BBRA regarding the
consolidated billing requirements. Routine and non-routine medical supplies furnished to a
patient during the time he or she is under a plan of care of a home health agency are bundled into
the episode rate. Therefore, in the example, the home health agency is responsible for providing
the catheter supplies while the patient is under a plan of care even though those supplies are
unrelated to the plan of care. The PPS episode payment will reimburse the HHA accordingly.
Q: Does agency discharge with goals met negate the agency's financial responsibility for Part B
supplies and services that the patient needs/uses after the agency discharge but before the end of
the 60-day episode?
A: Yes. The home health agency is responsible for Part B supplies and services only while the
patient is under the plan of care. Once the patient is discharged, the agency is no longer
responsible for providing those Part B supplies and services.
Q: Please define "covered and paid for"; the description of non-routine medical supplies for
which the agency is now responsible.
A: Section 206.4 of the HIM-11 lists some non-routine medical supplies that were covered and
paid for but this is not an all-inclusive list. We are preparing an all-inclusive list and will post it
on the home health web page.
Q: Will agencies be required to cover incontinence supplies; adult diapers and disposable
underpads?
A: Yes incontinence supplies are covered to the extent they were covered under the existing cost
based home health benefit.
Q: Will the agency determine which supplies are for "wound care", or will HCFA be issuing a
list?
A: HCFA does intend to let agencies determine which supplies they report under the optional
HH PPS wound care supply reporting on claims (use of revenue code 623 as per HCFA
website/forthcoming instructions). This reporting should only entail the non-routine supplies
used directly for wounds; not all non-routine supplies used for wound-care patients, and should
be exclusive of any other supplies reported on the same claim under other revenue codes.
However, since several requests for additional guidance on use of this option have nonetheless
been received, HCFA will get the knowledgeable sources together, reach consensus on specific
items, and provide further guidance in the next few weeks.
Q: Under HHPPS, does the physician's plan of care still have to include specific orders for all
non-routine supplies, including those not directly related to the home health visit? For example,
if a nurse is providing wound care to a bene on a bi-weekly basis and the bene also has an
ostomy bag, does the POC have to specify the provision of the ostomy bags?
A: Ordinarily, it is preferable to have orders for supplies.. However, we could envision a
circumstance where a physician would be uncomfortable with writing orders for a pre-existing
condition. We are exploring the use of PRN orders as part ot the HIM-11 revisions. The
comprehensive nature of current patient assessment and plan of care requirements looks at the
totality of patient needs.
Q: How do the consolidated billing requirements governing Medicare home health PPS and the
rate methodology relate to a Veteran who is receiving medical supplies from the VA?
A: For Veterans, both Medicare and VA payments are primary, so the beneficiary has some
choices in cases where the benefits overlap. VA "payments" by Medicare are excluded by law,
however, this exclusion is implemented in the PPS base rather than by excluding services on a
case-by-case basis. VA payments were excluded in the base rates. Exclusion of VA payments is
global. An HHA must provide the supplies a patient needs; it is not obligated to provide medical
supplies that a patient doesn't need. If a patient has supplies provided by the VA because of the
patient's preference, then the HHA is not required to duplicate supplies. The HHA may not
require the beneficiary to obtain or use medical supplies from any other source, including the
VA. However, the beneficiary's choice is controlling. If the beneficiary wants medical supplies
provided by the Medicare participating HHA, then the beneficiary must receive the supplies from
the Medicare participating HHA.
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Wound Care:
Q: How should home health agencies bill for physical therapy visits made solely to perform
wound care (in those states where permitted by their practice acts)? If billed as physical therapy
visits, will they count toward the therapy threshold?
A: If wound care falls within the auspice of the state practice act for physical therapists, they
may provide the specific type of wound care services defined in their state practice act. Such
visits in this specific situation can be billed as physical therapy visits and will count toward the
therapy threshold. If the visits were found to be excessive or not medically reasonable and
necessary as part of medical review, the visits will be considered non-covered regardless of who
is providing the visit.
Q: Where is the policy referenced on page 41151 of the Federal Register, which holds that
"wound care must be efficacious", as well as finite and predictable to be covered? When was this
policy promulgated?
A: The concept that wound care must be efficacious is inherent in the definition of medically
reasonable and necessary services. Medically reasonable and necessary services are safe and
effective ones. If an agency persists over an extended period in delivering daily skilled wound
care services that do not result in improvement, then the services cannot be said to be effective.
The concept of "finite and predictable" need for services comes from the Medicare home care
eligibility requirement (promulgated in Sections 1814 and 1835 of the Social Security Act). It
states that patients are eligible if they need intermittent skilled nursing services. Intermittent for
eligibility means skilled nursing that is either provided or needed on fewer than 7 days each
week, OR less than 8 hours of each day for periods of 21 days or less (with extensions in
exceptional circumstances when the need for additional care is finite and predictable).
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RAPS:
Q: Will RAP payments be withheld from all home health agencies that are under focused
medical review? Has HCFA established specific criteria for withholding RAP payments?
A: As stated in the regulation text of the final home health PPS rule at § 409.43 (D)(2), "HCFA
has the authority to reduce or disapprove requests for anticipated payments in situations when
protecting program integrity warrants this action."
Our medical review criteria are under development. We may refine our approach to the medical
review of RAP payments based on agencies' behavior under the first year of PPS.
Q: May a home health agency cancel and resubmit a RAP in those instances where therapy visits
that were predicted to be below the threshold but were increased to reach or exceed the
threshold, or is a SCIC required?
A: If the therapy threshold MO825 is the only case mix item that requires adjustment due the
patient's condition, the HHA has the option to cancel and resubmit a RAP or SCIC, as
appropriate, to adjust the episode. The determination of whether a the resubmission of a RAP or
a SCIC is appropriate is dependent upon whether the additional therapy services was a result of a
significant change in the patient's condition. The intermediary system will not automatically
upgrade a non-therapy HHRG to a therapy HHRG when the final claim indicates 10 or more
therapy visits.
Q: Must home health agencies wait until a billable visit is made before submitting a RAP for
subsequent episodes when continued care is anticipated? For example: May home health
agencies submit RAPs on all patients on service 10/1/2000 (if HHRG and verbal order
requirements are met) regardless of whether they have had a visit? When may an agency submit
a RAP for the second episode for a patient who has completed an episode, has a new grouper and
verbal orders for the second episode beginning 11/30/2000, but does not have a home visit until
12/4/2000?
A: Even though we are deeming a start of care date of 10/1/2000 for all established patients
under a home health plan of care, an actual billable visit must be rendered prior to the submission
of a RAP. For service dates on or after 10/1/2000, a billable visit must be rendered prior to the
submission of a RAP for all new episodes and subsequent episodes.
Q: If the primary agency does not discharge a patient at the end of an episode, will that agency
be recognized as the primary agency for subsequent epsiode(s) even though a RAP has not yet
been submitted for the subsequent episode(s)?
A: No. HCFA systems react to a RAP or claim that that is submitted for an eligible beneficiary
during a discrete 60-day time period. An HHA must establish its primacy for each episode for
each eligible beneficiary.
Q: From a recent association listserv, it was noted the default logic built into the PPS claims
processing system will allow a second agency to bill and receive payment even if a primary
agency has a RAP on file for overlapping dates of service. The primary agency will be denied
payment for overlapping dates of service. It was our original understanding this could only occur
if the second agency admitted the patient as a transfer. Please clarify and comment.
A: The primary HHA will only be denied payment for overlapping dates of service in the
situation of a PEP transfer with a transfer indicator of 06 in the patient field of the RAP of the
transfer HHA. Unless there is a 06 transfer indicator in the patient field of the RAP of the second
HHA in an open 60-day episode, the second HHA's RAP will be rejected.
Q: Can the agency submit a RAP in the initial episode after receiving verbal orders and making
the first billable visit, with OASIS data submission to follow within the specified time
parameters?
A: Even though we are deeming a start of care date of October 1, 2000 for all established
patients under a home health plan of care, an actual billable visit must be rendered prior to the
submission of a RAP. For service dates on or after October 1, 2000, an actual billable visit must
be rendered prior to the submission of a RAP for all new episodes and subsequent episodes. The
OASIS data must be locked for transmission before the submission of a RAP. The actual OASIS
data transmission to the State may follow within the ordinarily specified time parameters for
OASIS transmission.
Q: For ongoing episodes, can the agency submit the RAP based on verbal orders to continue care
without waiting until the first visit in the episode?
A: As stated above, an actual billable visit must be rendered before the submission of a RAP for
new and subsequent episodes.
Q: Does meeting the requirements for Locator 23 satisfy the verbal order requirement for the
RAP?
A: As stated in section 234.7 of the HIM 11, Locator 23 may be used to document receipt of
verbal orders when services are furnished prior to the physician written orders, SOC, or
recertification. If this field is used, the order must be written on the Form 485 and signed and
dated with the date of receipt by the nurse, qualified therapist, social worker or qualified health
professional to begin or modify or continue care at recertification.
RAPs cannot be submitted earlier than the date of the provision of the first billable visit and
documentation requirements for the plan of care regarding physician orders have not changed.
Q: Does your answer change to #6 if the patient was assessed during the correct timetable, but
the data was not locked or transmitted on time?
A: No. The OASIS data must be locked for transmission prior to the submission of a RAP. The
actual OASIS data transmission to the State may follow within the ordinary specified time
parameters for OASIS transmission.
Q: If our agency decides not to submit RAPs during October, will we be paid 60 percent or 100
percent when we submit the claim?
A: All initial RAPs will be paid 60 percent regardless of whether they are submitted in October
or after the phase in period.
Q: Will all RAPs submitted in October be subject to the phase in plan, or only the RAPs
submitted on October 1?
A: All RAPs submitted on or after 10/1/00 up until the phase-in plan terminates with full, current
processing will be subject to the phase in plan.
Q: Is an October visit required before a RAP can be submitted for those September patients still
on service in October?
A: Yes.
Q: The latest HIM 11 revision states that September claims must be "closed" before doing an
October RAP. Define "closed".
A: The end date for September claims is 9/30/00. "Closed" refers to the submission of the final
claim under cost-based payment which ends on that date.
Q: With initial RAP payment, I believe we lose our ability to appeal a denial by our FI.
1. Do you feel we will have more Requests for Information generated by our FI?
2. Is there any recourse if a claim from an initial RAP is denied?
A: 1) At this point, Medical Review will not be directing the majority of its resources to RAPs
but to final claims. 2) No. A RAP is not a claim so it is not subject to normal appeals processes.
If a RAP is not paid and you wish to question the basis for the non-payment, consult your FI.
Q: Why can't RAPs be seen individually instead of batched on remittance advice (e.g. 16 RAPs
for $xxx revenue)?
A: When full processing begins after the phase-in, RAPs will be shown individually on the
remittance advice. The RAPS were batched on the remittance advice because of system
limitations related to the phase-in period.
Q: If an agency is on focused medical review can they still receive RAP payments?
A: Yes. The agency may still receive RAP payments. The basis for withholding RAP payments
is due to significant program integrity concerns.
Q: For a subsequent episode can the RAP be submitted if the 1st visit for an ongoing patient is by
the aide?
A: A billable service must be rendered before a RAP may be submitted for any episode. A visit
by a home health aide qualifies as a billable visit for purposes of RAP submission.
Q: Should a RAP be submitted on a known LUPA case? We have been told by intermediary that
it could be construed as fraud.
A: A HHA has the option of submitting a No-RAP LUPA claim after the 4 or fewer visits are
provided or submitting a RAP up front even though they know the episode will require a LUPA.
The second option would require a payment adjustment by the FI after the agency submits the
claim for the LUPA.
Q: If an HHA submits a final claim for an episode with a patient's status 30 (still a patient) and
before they submit the RAP for the next subsequent episode, can another HHA submit a RAP
with a source of admission 1 (physician referral) and receive payment?
A: Yes. Each episode stands on its own. If the second episode begins and another agency submits
a RAP first, that agency becomes the "primary" for the second episode.
Q: Is it true that any patient that could be in a possible MSP situation will not have a RAP paid?
Please explain this could be every patient that agencies have on service with a diagnosis in the
"800" range (trauma Dx).
A: Yes. Medicare will make secondary payments on claims only, not on RAPs. Providers may
wish to track primary payer services in the same 60-day increments.
Q: Does the verbal order for the Request for Anticipated Payment (RAP) only have to be written
and sent to the physician for signature or does the verbal order need to be signed by the physician
before submission of the initial episode's RAP?
A: The verbal order for the RAP only has to be sent to the physician. It does not have to be
signed before being submitted. The plan of care must be signed and dated by the physician prior
to submitting the claim for the final percentage of the episode payment.
Q: Does the first billable visit have to be rendered before the RAP may be submitted?
A: In all cases, without exception, a service must be delivered before a RAP may be submitted.
Q: Does the OASIS have to be locked and transmitted before the RAP may be submitted?
A: No. The OASIS does not have to be locked AND transmitted. The OASIS only has to be
locked for transmission but not actually transmitted before the RAP may be submitted.
Q: Can the RAP and the final claim for the same episode be submitted for the same patient in the
same submission file?
A: Yes. But there is a risk that the final claim might be processed before the RAP is processed. If
this happens, the final claim would be returned to the provider.
Q: Is there a specified period of time between a discharge and the start of care with a new
episode to qualify for the 60/40 split? For example, if the patient is in the hospital on days 58
through 62, the patient must be discharged from home health. The patient returns home on day
63 and the home health agency re-admits on day 64. Will the new episode be given a 60/40 split
percentage payment?
A: There is no specific requirement for the length between episodes. Once there is any gap
between episodes, the new RAP should be submitted as an initial episode.
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To and Through Dates:
Q: Must agencies specify visit frequency, duration and all treatments for both pre-PPS orders
(through 9/30/2000) and post-PPS orders (10/1/2000 through and including 11/29/2000) on the
485?
A: Current plan of care requirements govern the one-time optional grace period provided to
HHAs associated with PPS implementation. The documentation requirements should follow
regulations at §§409.43 and 484.18.
Q: When writing orders under PPS, should home health agencies complete the 485 "to" date to
reflect the day after the end of the episode since the current instructions for completing the 485
state that the "to" date is "up to but not including" that date. Will HCFA change the HIM-11
instructions for completing the 485 "to" date to read "up to and including" in order to simplify
this in the future?
A: We will revise section 234.7 of the HIM-11 to reflect the policy change that governs the
corresponding change to the "to" dates on the 485. The 60-day episode requires us to change the
current language governing the "to" date for the exact reason stated in your question. We do not
want to double count the last day of an episode for a patient on continuous care. Therefore, the
language must reflect a start of care date plus 59 days. The subsequent episode begins on day 61
not day 60. The current language in the HIM-11 will be revised in a manner which reflects the
idea of your suggested language that the "to" date on the 485 indicates "up to and including" the
last day of the episode which is not the first day of the subsequent episode. The exact language
has not been finalized.
Q: Will the diagnoses and clinical information contained on the 485 be adequate information to
fulfill the requirement that a description of the patient's status must appear on a verbal order?
A: The current requirements governing physician verbal orders in the plan of care govern the
requirements for submission of a RAP.
Q: For plan of care preparation under PPS should the initial "TO" dates be November 29 or
November 30?
A: The first 60-day episode for established home health beneficiaries spans October 1, 2000 to
and including November 29, 2000. The planned revisions to section 234.7 of the HIM 11 are
discussed in response to question #11.
Q: Does HCFA plan to modify Locator 3, certification period, on the HCFA 485 to read "From"
and "Through," instead of "From" and "To"? Visits made on the "To" date (or last date of the
certification period) are not covered by the plan of care. However, in the PPS episode, visits
made on the last date of the episode are covered.
A: As stated in our response to your previous question, we will be revising section 234.7 of the
HIM-11 governing Locator 3 in order to reflect the change in the "to" date requirements for all
60-day episode certification periods. The 60-day episode requires us to change the current "to"
language because we do not want to double count the last day of an episode for a patient on
continuous care. The language must reflect a start of care date or recertification date plus 59
days. Any subsequent episode must begin on day 61 not day 60. The HIM-11 will reflect a "to"
date on the 485 that indicates "up to and including" the last date of the episode which is not the
first day of the subsequent episode. The exact language has not been finalized.
Q: If this change will not be made in time, how will agencies need to complete Locator 3 in the
PPS? One suggestion for a contingency plan: Modify the interpretation of "To" so the
certification period will cover visits made on that date. Agencies will be able to enter the episode
dates as the certification period, e.g., October 1 through November 29.
A: As stated in our response to the previous question, we are taking a similar approach to the
revision of 234.7 of the HIM 11. We believe the preamble and regulation text of the final PPS
rule published in the Federal Register on July 3, 2000 reflects the policy that the 60-day episode
includes the start of care date plus 59 days.
Q: NAHC published an article stating that HCFA had clarified the "to" and "through" dates and
that HCFA would be redefining the "To" date on the 485. Is this for sure? When?
A: Yes. Program Memorandum A-00-71 effective October 2, 2000 changes the definition of the
"To" date to mean "up to and including the last day of the episode which is not the first day of
the subsequent episode. You may access this program memo at
http://www.hcfa.gov/pubforms/transmit/A0071.pdf
Q: Is there a penalty if Plan of Care has "To" date of 11/30/2000?
A: The implementation date for the Program Memorandum A-00-71, which changes the
definition of the "To" date, is October 30, 2000. Therefore, as long as you begin to use the "To"
date according to the new definition meaning "up to and including the last day of the episode" on
and after October 30, 2000, there shouldn't be any problem.
Q: Our vendor will not change the "to" dates on the 485 until the HIM-11 is changed. Is it a
problem if our 485 shows 10/1/00 - 11/30/00 as long as our bills are for 60 day periods?
A: Effective with Program Memorandum A-00-71, the HIM-11 is now changed. The
requirement for the change to the "To" date must be implemented by October 30, 2000.
Q: Are existing patients' start of care dates to be changed on their 485 to 10/1/00?
A: Existing patients' start of care dates will be 10/1/2000.
Q: Since PPS is episodic, why not change 485 orders to reflect this? Example: SN 10v/60 days.
This reflects flexibility based on patient needs.
A: It does not necessarily follow that a payment system that is based on a 60-day period of time
should have a plan of care such as the one you suggest. The plan of care requires more detail as
to the frequency of visits over the course of the episode.
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MSP:
Q: How will an agency's Medicare payment be calculated when the primary payment is under a
capitated contract that does not include all home health services (e.g., home health aide) but the
patient requires these services?
A: If an HHA has a contract with a managed care entity to furnish Medicare covered home
health services, then the eligible beneficiary receiving services from the managed care entity is
entitled to receive covered home health services from that managed care entity. The managed
care entity may decide to use more than one HHA to provide the scope of covered home health
services. Therefore, no further payment would be made for home health services under PPS.
Q: Will an agency receive full episode payment when a patient no longer qualifies for Medicare
home health services before day 60 but receives noncovered services paid by another source? For
example: Skilled nursing is no longer needed as of day 35 but the patient requires aide services
after that date and Medicaid will pay for the aide.
A: As discussed on page 41162 of the final rule, if a patient is discharged because he or she is
ineligible for the home health benefit, a full episode payment will be made to the HHA unless the
patient becomes subsequently eligible for home health during the same 60-day episode and later
transferred to another HHA or returned to the same HHA. The latter situation would result in a
PEP adjustment.
Q: What Medicare payment will home health agencies be entitled to in those cases where
Medicare is the secondary payer and coverage of service by the primary payer does not include
all home health services? How should billing be done?
Example: How will Medicare pay for aide services to a beneficiary whose primary insurance is
through his working wife's Blue Cross policy when the BC coverage is limited to skilled
services.
A: In cases where a primary payer (e.g., a group health plan) doesn't cover certain home health
services, Medicare will pay primary for these services if the services are Medicare covered
services. We would pay the claims according to normal PPS rules with regard to the visits not
covered by the other payer. Medicare will make secondary payments on claims only, not on
RAPs. On the claim on item 50, the Payer field, providers should enter the primary payer on line
A, secondary payer on line B, and tertiary payer on line C.
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Claims Processing:
Q: Please explain the advantages of establishing a home health agency as the primary agency in
light of the fact that the claims processing system has been set up to return primary agencies'
claims (and requires the primary to bill to the secondary for overlapping dates of service) when
another agency subsequently submits a claim for overlapping dates? Shouldn't the "beneficiary
elected transfer" be recognized by a more formal process than the submission of a claim by
another agency?
A: The primary agency concept was developed to implement legislatively mandated consolidated
billing for HH. The same law that created consolidated billing also required beneficiaries be able
to exercise choice in their HH providers under the new PPS system. HCFA believes the
mechanisms as now constructed is the best available option for timely implementation of those
mandates within the constraints of existing Medicare claims processing systems.
Q: What is the status of requirements to submit "noncovered charges" on the home health claim?
If these will be required, when will HHAs receive detailed instructions on what must be included
and how to itemize these charges on the final claim?
A: HCFA Program Memorandum A-99-49, released in November 1999, provided all available
guidance on this subject. The effective date for this requirement is October 1, 2000. Although
PM A-99-49 was rescinded in June, it outlines how HHA's will be billing non-covered charges
once the instructions are re-instated.
Q: In our earlier letter we asked for clarification related to the overlap of home health visits with
inpatient admission and discharge dates you responded that you were discussing this issue with
your HCFA systems. (Attachment A, Answer 20.) We would appreciate a similar clarification
when a home health patient has a covered visit on the date of death.
A: The claims processing systems allow same day transfers both to and from SNFs and inpatient
facilities. Overlapping claims will not reject in situations in which visit dates happen during the
inpatient stay. Regarding the second part of your question, our systems allow a home health visit
on the patient's date of death.
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Discharge Rules/ Eligibility:
Q: Home health agencies define discharge date differently. Some use the last visit date, some use
the date they were notified that services are no longer needed, and others use the date that the
discharge documentation is completed. Please define discharge date as it appears on the home
health claim. Should the definition match the definition for OASIS?
A: HCFA is currently working on developing such uniform definitions for HH PPS claims
processing purposes. However, note that visits under HH PPS must fall on the beginning, ending
or within an episode period (i.e., on or between the from and through dates on the claim for the
episode), and that the through date represents the end of a given episode (i.e., 59 days added to
the from date, or discharge, if earlier).
Q: Thank you for confirming that these are acceptable reasons, other than "goals met", for
discharging a patient enabling an HHA to receive the full episode payment. (Attachment A,
Answer 4) However, we believe the final statement in that response "physician orders may be
obtained if the discharge is prior to the projected end of the treatment in the plan of care") is
erroneous. NAHC was advised in a July 20, 1992 HCFA letter that the Medicare conditions of
participation do not require a discharge order. (Attachment B.)
A: You are correct. Current conditions of participation do not require a discharge order. We
apologize for the error and have requested that that sentence be removed from that particular
answer on our web site.
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Recertification Window:
Q: The assessment completion date (M0090) must be set within a five-day window that ends 60
days from the start of care date and recertification assessment dates must be completed within a
5-day window ending 120, 180, 240 etc. days from the start of care dates. When dates outside of
this window occur will RAPs and claims be rejected? What, if anything, would happen?
A: The 5 day reassessment window is a condition of participation requirement. Failure to meet
these requirements carry their own sanctions unrelated to RAP and claim submission.
Q: Assume we miss the OASIS assessment timetable (days 56-60) for reassessment, but the
patient is eligible for Medicare home health services. Can we assess the patient when this
oversight is detected and use that as the basis for payment for that episode, or do I provide
uncompensated care during for this episode? If I can assess when oversight is detected, what date
do I use for the start of the episode?
A: As discussed in response to Question #24 of this document, the 5 day reassessment window is
a condition of participation requirement. Failure to meet these requirements carry their own
sanctions unrelated to RAP and claim submission.
Q: If a patient is admitted to an in-patient facility (hospital) and is not discharged from the HHA
at the time of recertification - during the 5 day window for recertification - do you discharge the
patient from the HHA, and readmit post hospital visit, or do you do the recert on the first visit
post hospital stay?
A: You discharge the patient from the HHA and then readmit then to the HHA after they are
discharged from the inpatient facility. If the hospital stay overlapped into what would have been
the subsequent episode, the certification begins with the new Start of Care.
Q: Can you give us a larger window in November for the renewal of continuing patients - OASIS
& Recertifications all due in 5 days?
A: No. We do not have the latitude under current law and regulations to provide for an additional
grace period. We instructed State agencies to exercise discretion regarding enforcement of this
issue.
Q: Has there been any discussion in allowing an extension to the 5 day Recert window for the
11-29-00 Recerts due to the large volume that will occur, which will cause a further challenge to
HHAs? Is there anything that can be done to get an extension?
A: (As above.) No. We do not have the latitude under current law and regulations to provide for
an additional grace period. We instructed State agencies to exercise discretion regarding this
issue.
Q: If a patient is transferred to the hospital without agency discharge as POC goals had not been
met and the patient resumes Home Health care after the 60th day of the initial episode, it is
understood the resumption of care (RFA 3) would be completed within 48 hours of the patient's
return, when would the recertification (RFA 4) be completed? The recert is usually required
within 5 days of the 60th day of the previous episode, the patient in this case is still in the
hospital.
A: When the patient was admitted to the hospital, the HHA completed a transfer assessment
without discharge (RFA #6), the patient was not discharged, as goals were not met on day 50 for
example. As the patient was in the hospital during the five-day recertification window, the HHA
could not complete the Follow-up OASIS. The transfer assessment completes the first episode
for both the Outcome Report and the PPS system. A final bill can be submitted by the HHA on
day 60 for the first episode and the patient is discharged from the HHA.
When the patient is discharged from the hospital and returns home, the HHA can begin a new
episode on the first billable visit after the hospital discharge. The agency now provide a new
SOC assessment to project the therapy needs of the patient in this new episode, complete a new
485, and obtain new physician orders.
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PEPs:
Q: May a home health agency discharge a patient who is admitted to an inpatient facility
(hospital, SNF, rehab facility) and receive a PEP payment followed by a new episode if that
patient returns to the agency's care within the same 60 day period?
A: As discussed on page 41162 of the preamble of the final home health PPS rule published on
July 3, 2000 in the Federal Register, we believe that HHAs should be given the option to
discharge the patient within the scope of its own operating policies; however, an HHA
discharging a patient as a result of hospital [SNF or rehab facility] admission during the 60 day
episode will not be recognized by Medicare as a discharge for billing and payment purposes. An
intervening hospital [SNF or rehab facility] stay will result in either an applicable SCIC
adjustment or, if the resumption of care OASIS assessment upon return to home health does not
indicate a change in case-mix level, a full 60 day episode will be provided spanning the start of
care date prior to the hospital [SNF or rehab facility] admission, through and including the days
of the hospital admission, and ending 59 days after the original start of care date. If the HHA has
discharged the patient and billed the claim for the patient and does not cancel the claim and rebill for the episode when the patient returns from the inpatient stay, then Medicare systems will
PEP the prior episode and start a new 60 day episode clock. Failure to cancel the claim and rebill in this situation may financially disadvantage the HHA. There are pending clarifications to
the billing instructions.
Q: Is an agency paid a SCIC or a PEP payment when a patient is discharged from and returns to
the agency within a 60 day period for reasons other than "goals met?" Such discharge reasons
could include: no longer qualify for home health, services are not covered, safety issues,
noncompliance as discussed in the preamble of the final rule.
A: As stated on page 41162 of the preamble of the final rule: "If a patient is discharged because
he or she becomes no longer homebound and therefore ineligible for the home health benefit,
refuses services, or becomes a documented safety, abuse or noncompliance discharge during the
60-day episode, the HHA would receive a full 60-day episode payment unless the patient became
subsequently eligible for the home health benefit during the same 60-day episode and later
transferred to another HHA or returned to the same HHA, then the latter situation would result in
a PEP adjustment." The HHA would be paid the PEP adjustment to the original episode payment
in the latter situation.
Q: In calculating PEP and SCIC payments for subsequent episodes where at least the first day of
the episode does not include a billable visit will the proration occur with the first day of the
subsequent episode or the date of the first billable visit in the subsequent episode?
A: The PEP and SCIC payments for subsequent episodes are calculated based on billable visit
dates.
Q: If a patient is discharged with goals met on Day 20 of an episode and is readmitted on Day 40
with an exacerbation of the same diagnosis, is it considered part of the original 60 day episode or
a new episode?
A: This is a clinical judgement situation. If the exacerbation was due to a premature discharge,
then the beneficiary would be considered in the original 60-day episode. If the goals were truly
met, then the situation would result in a PEP adjustment.
Q: Please clarify the response for this situation: If a patient was discharged because he or she did
not qualify for Medicare coverage and was later readmitted to the same agency, would this result
in a PEP and a new episode? If so, it is irrelevant that the patient was discharged with the goals
unmet. Or would the agency be looking at two PEPs? If so, there could be a problem with
OASIS data entry. If the agency discharged the patient, staff have 48 hours to complete a
discharge OASIS. When the patient returned, the nurse would do the SOC assessment; however;
the agency would not be starting a new episode.
A: As discussed on page 41162 of the final rule published in the Federal Register on July 3,
2000, if a patient is discharged because he or she is ineligible for the home health benefit, a full
episode payment will be made to the HHA unless the patient becomes subsequently eligible for
home health during the same 60-day episode and later transferred to another HHA or returned to
the same HHA. The latter situation would result in a PEP adjustment.
Q: If the patient is discharged from Medicare, receives services under Medicaid, and then
becomes subsequently eligible for Medicare coverage during the same episode, will the agency
receive a PEP and begin a new episode?
A: As discussed above, if a patient is discharged because he or she is ineligible for the home
health benefit, a full episode payment will be made to the HHA unless the patient becomes
subsequently eligible for home health during the same 60-day episode and later transferred to
another HHA or returned to the same HHA. The latter situation would result in a PEP
adjustment.
Q: If the patient transfer to HMO during the 60 day of care, does the agency receive PEP or full
episode payment?
A: As stated on page 41162 of the final rule, if a beneficiary becomes HMO eligible midepisode, the 60-day episode payment will be proportionally adjusted with a PEP adjustment.
Q: If a PEP occurs, does this shorten the timeframe allowed for us to bill, or do we still have
until 60 days past the date the episode would have ended if it were not interrupted?
A: No. PEP does not effect the timeframe governing billing procedures.
Q: If patient is discharged without goals being met (e.g., refused services, noncompliance) and
then they return before the original 60-day episode has expired, is the original episode payment
subject to a PEP adjustment?
A: As discussed on page 41162 of the preamble of the final rule, if a patient is discharged
because he or she becomes no longer homebound and therefore ineligible for the home health
benefit, refuses services, or becomes a documented safety, abuse or noncompliance discharge
during the 60-day episode, the HHA would receive a full 60-day episode payment unless the
patient became subsequently eligible for the home health benefit during the same 60-day episode
and later transferred to another HHA or returned to the same HHA, then the latter situation
would result in a PEP adjustment.
Q: Please provide an example of a calculation of an episode that includes a PEP and also
qualifies as an outlier.
A: For purposes of this example, assume that the HHRG is C2F2S2 and the HHA is serving a
beneficiary in State College, PA. This is the same HHRG and the same wage index used in the
outlier example which starts on page 41189 of the final rule. Based on the example using HHRG
C2F2S2 and wage index .9139, the case-mix and wage-adjusted episode amount would be
$3,855.31 and the outlier threshold would be $6,085.76 for a full 60-day episode. However, if
the episode was due a PEP because of an intervening event such as transfer to an inpatient
facility, the outlier threshold would be calculated differently.
The payment is prorated based on the PEP rules, but the fixed dollar loss is not. Note that the
outlier threshold will be lower in the PEP case, but it is because the payment is prorated, not the
fixed dollar loss. The underlying idea is that a dollar lost is a dollar lost no matter what type of
case is involved (PEP vs. regular episode; one HHRG vs. another HHRG, etc.). Hence the same
loss must be experienced before a case qualifies for outlier payments.
Let's assume the patient transferred to an inpatient facility on day 51 with day 50 being the day
on which the last billable visit was rendered. Let's also assume that the first billable visit was
actually rendered on day 1 of the episode. We would calculate the episode payment as follows:
$3,855.31 * 50/60 = $3,212.76. The wage-adjusted outlier threshold for the partial episode
would be equal to the PEP plus the wage-adjusted fixed dollar loss amount. The wage-adjusted
fixed dollar loss amount is still $2,230.45. Therefore, the wage-adjusted outlier threshold for the
partial episode = $3,212.76 + $2,230.45 = $5,443.21.
Now let's look at the actual services rendered. Suppose 20 skilled nurse visits, 45 home health
aide visits, 3 medical social service visits, and 15 occupational therapy visits were rendered.
Using the per visit payment amounts from Table 6 of the final rule, the non-wage adjusted costs
for these types of visits would be as follows:
Skilled nursing: 20 * 95.79 = $1,915.80
Home health aide: 45 * 43.37 = $1,951.65
Medical social services: 3 * 153.55 = $460.65
Occupational therapy: 15 * 105.44 = $1,581.60
Using the State College, PA wage index of 0.9139, a labor portion percentage of .77668, and a
non-labor portion percentage of .22332, the wage adjusted costs are as follows:
Skilled nursing: (1915.80 * .77668) (.9139) + (1915.80 * .22332) = $1,787.69
Home health aide: (1951.65 * .77668) (.9139) + (1951.65 * .22332) = $1,821.14
Medical social services: ( 460.65 * .77668) (.9139) + ( 460.65 * .22332) = $429.84
Occupational therapy: (1581.60 * .77668) (.9139) + (1581.60 * .22332) = $1,475.84
Adding the costs for each of these disciplines results in a cost of $5,514.51 for the partial
episode. This cost exceeds the outlier threshold of $5,443.21. The amount that is in excess of the
outlier threshold is 5,514.51 - 5,443.21 = $71.30. Using the risk sharing ration of 80%, the
outlier payment would be 71.30 * .80 = $57.04. The total payment for the partial episode
including the outlier payment would then be 3,212.76 + 57.04 = $3269.80.
Q: If a Medicare beneficiary enrolls in an HMO during the course of a 60-day episode, but the
HMO does not order continued home health services, will the HHA receive a full episode
payment since the patient will be discharged from home care?
A: The HHA will receive a PEP for the episode.
Q: The OASIS does not appear to require obvious responses to "GOALS MET" or "Transfer to
another Home Health Agency" on discharge, which could result in a PEP. Does an "NA"
response to M0855 indicate a possible PEP? If not, what are the indicators HCFA would use to
recognize a PEP (other than 06 on the final claim)?
A: The OASIS does not indicate a PEP. HCFA will recognize a PEP by a 06 in the patient status
field on a claim, "B" or "C" on the source of admission of a RAP (PEP would be to previous
episode) or the result of an automatic adjustment in Medicare systems when there is an overlap
between episodes for a single beneficiary.
Q: In calculating PEP and SCIC payments for episodes, which are not initial, will the proration
occur with the first day of the subsequent episode or the date of the first billable visit in the
subsequent episode?
A: For episodes that are not initial, the date of the 1st billable visit will be used.
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Payment:
Q: If a patient has a Start of Care of September 12, 2000, and a Plan of Care is done for
September 12, 2000 to November 12, 2000, will we get paid under PPS for the period of October
1, 2000 to November 12, 2000 since it is less than 60 days. Or, must we make all Plans of Care
or Follow Ups in September 2000 end on November 29, 2000 and use the entire "Grace Period"?
A: If an HHA takes advantage of the optional, up to a maximum 90 day, grace period for plan of
care certification for established home health beneficiaries that reflects the first 60 day episode
(October 1, 2000-November 29, 2000) and up to a maximum of 30 days in September 2000, the
HHA must reflect the physician orders (e.g., discipline, frequency, duration etc.) for services for
pre-PPS services (September 1, 2000 through and including September 30, 2000) and post-PPS
services (October 1, 2000 through and including November 29, 2000). The pre-PPS services
(September 1, 2000 through and including September 30, 2000) would be paid under cost
reimbursement under the interim payment system. Services rendered on or after October 1, 2000
will be paid under the new PPS.
Q: Can agencies use less than the 60 day period from October 1 - November 29 and be
reimbursed?
A: For established beneficiaries, the first 60-day episode effective with PPS is October 1, 2000
through and including November 29, 2000. Unless there is an applicable PEP adjustment (e.g.,
transfer) there can only be one open 60 day episode that spans the period of October 1, 2000
through and including November 29, 2000 for established beneficiaries. However, a patient's
plan of treatment may indicate goals can be reached in a time period that is less than a full 60 day
period. Unless there is an applicable PEP adjustment, the HHA would be paid the full 60 day
episode for a period that ends before the 60th day if the goals in the treatment plan warranted a
shorter period.
Q: If a patient needs HHA services until October, do we need to discharge and readmit patient in
September?
A: No. HHAs may take advantage of the optional grace period for plan of care certifications for
established beneficiaries whose care spans the effective date of October 1, 2000 of PPS.
Q: If the agency had completed a resumption of care assessment on or after September 1, 2000,
could it use that assessment to establish the HHRG? It contains the same data element as the start
of care assessment?
A: As part of the one-time implementation grace period for beneficiaries under an established
home health plan of care in September 2000, home health agencies (HHAs) may use the most
recent start of care, resumption of care or appropriate follow-up OASIS assessment to group
patients for case mix purposes for the October 1, 2000 effective date of home health PPS. In
order to take advantage of the optional PPS implementation grace period for OASIS assessments,
HHAs must use the OASIS B-1 (8/2000) that includes all necessary OASIS items for case mix
classification under PPS.
Q: Will there be any problems in the PPS or with OASIS data submission because of the start of
care date for the earlier version of the OASIS assessment would be prior to October 1, 2000?
A: We do not foresee any problems with the one-time OASIS implementation grace period.
Q: How would an agency complete one plan of care that incorporates two start of care dates?
Locator 2 on the HCFA 485 includes space for only one date.
A: The optional implementation grace period for plan of care certifications provides a one-time
up to 90 day certification period that includes the first 60-day episode beginning on October 1,
2000 and includes up to 30 additional days in
September 2000. As discussed in the final rule, the optional grace period plan of care
certification must distinguish between the pre-PPS and post-PPS physician order services. The
documentation date must reflect the break in physician ordered services up to September 30,
2000 and the physician ordered services for dates on or after
October 1, 2000 for the first 60-day episode. There are a couple of approaches to your question.
First, the HHA may put both the previous start of care date for established patients and the new
PPS start of care date in locator 2 on the 485. Alternatively, the HHA may retain a duplicate
copy of the one time up to 90 day maximum plan of care certification that indicates the
established start of care date and the new PPS start of care date of October 1, 2000. Assuming
the plan of care includes the September 30, 2000/ October 1, 2000 split in physician ordered
services, the only difference in the duplicate copies of the 485 would be the established start of
care date in Locator 2 for established patients and the PPS start of care date of October 1, 2000 in
Locator 2 in the duplicate copy of the 485.
Q: How would this requirement for two start of care dates affect the completion of Locator 3,
certification period? The certification period begins with the SOC or recertification date. The
transition plan of care would have both a SOC date and a recertification date.
A: We will be revising section 234.7 of the HIM-11 governing Locator 3 in order to reflect the
change in the "to" date requirements for all 60-day episode certification periods. The 60-day
episode requires us to change the current "to" language because we do not want to double count
the last day of an episode for a patient on continuous care. The language must reflect a start of
care date or recertification date plus 59 days. Any subsequent episode must begin on day 61 not
day 60. The HIM-11 will reflect a "to" date on the 485 that indicates "up to and including" the
last date of the episode which is not the first day of the subsequent episode. The exact language
has not been finalized.
The effect of the optional implementation grace period for the plan of care certification for a
period of up to a 90 day maximum including the first 60-day episode under PPS beginning on
October 1, 2000 on Locator 3 of the 485 "from and to dates for the certification period" can be
addressed in a similar manner as our response to the previous question on Locator 2.
Q: What happens if an agency's software system does not permit it to enter certification period
that are more than 62 days?
A: The implementation grace period for both OASIS assessments and plan of care certifications
is optional and not a mandatory requirement.
Q: The comments in the final rule do not address patients who were admitted or recertified in
August. These patients' certification periods would end sometime in October. Example: SOC
August 20 with certification from August 20-October 20. How would agencies transition these
patients?
A: The grace period for plan of care certifications only allows up to a 90 day maximum period
that reflects the first 60-day episode for an established patient beginning on October 1, 2000 plus
an additional possible 30 days in September. As discussed previously. The physician ordered
services must reflect the break in ordered services pre-PPS for services ordered September 1,
2000 through and including September 30, 2000 under cost reimbursement and post-PPS ordered
services for physician ordered services for the first episode under PPS for established patients
October 1, 2000 through November 29, 2000, unless there is an applicable adjustment (e.g.,
transfer). Assuming your patient may well continue care after October 20, the patient in your
example could not be certified for a period of August 20-October 20. The HHA would have to
decide what break would be most effective for their caseload. For example. The HHA could do a
short certification period of August 20-August 31 and then take advantage of the up to 90 day
maximum certification period that would reflect pre-PPS September 1-September 30 and postPPS October 1-November 29. It is an option for the HHA as long as the October 1, 2000 start of
care and the first 60-day episode for PPS is reflected as a distinct period of time.
Any established home health patient who has a follow-up OASIS assessment due in August may
delay that assessment until any time in September and do the OASIS B-1 (8/2000) for grouping
purposes.
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Oasis:
Q: When will Medicare begin to use OASIS benchmarked data for PPS financial/licensing
decisions? Until then, what is HCFA going to do with OASIS data?
A: Initially, OASIS data will be used in our approach to outcome based quality improvement
activities and future case-mix refinements.
Q: If a patient is receiving services from multiple disciplines (e.g., SN, PT, HHA) and needs to
be hospitalized, does the nurse have to do the OASIS assessment upon discharge from the
hospital if it occurs before the episode elapses, or can the PT perform this task?
A: The rules governing who collects the OASIS assessment have not changed with PPS.
Q: Can a Resumption of Care OASIS be used to change a patient's case-mix after an inpatient
stay or must we do a follow-up OASIS as well? What if resumption of care is in last 5 days of
certification period?
A: If a patient is transferred to an inpatient facility and returns home before the end of the 60-day
certification period, the HHA conducts the ROC assessment in the usual fashion as required by
the OASIS regulations. The HIPPS code generated by this assessment can be used to bill for a
SCIC adjustment.
If the return home is during the last 5 days of the 60-day period and the agency intends to bill for
a SCIC adjustment, a ROC of care assessment would be conducted to bill for the SCIC
adjustment just as described above. Since the patient's return home coincides with the need to
prepare for the NEXT 60-day period, the HHA would also complete a Follow-up assessment,
bearing in mind that they are completing M0825 (the therapy item) with the NEXT 60-day
episode in mind. Note that one assessment could be conducted but 2 OASIS collections would be
completed, data-entered, and transmitted.
If the return home is during the last 5 days of the 60-day period and the agency DOES NOT
intend to bill for a SCIC adjustment, only a ROC of care assessment would be necessary, as is
the usual OASIS protocol when these time periods overlap. Bear in mind that if the HHA is not
billing for a SCIC adjustment and is conducting ONLY a ROC during the last 5 days of the
certification period, it must complete item M0825 (therapy item) with the NEXT 60-day episode
in mind, as this assessment will generate the HIPPS code that will be used to file the NEXT
RAP.
These items are discussed in detail in "OASIS Considerations for Medicare Patients" items #3 &
#4 on the OASIS web site at http://www.hcfa.gov/medicaid/oasis/oasisdat.htm#4.
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Diagnosis Coding:
Q: A patient is admitted to home health for care of complicated wound with new BKA secondary
to nonstable DM. Would the primary or secondary diagnosis be diabetes?
A: As discussed in section 234.7 of the HIM 11, the principal diagnosis must be related to the
current plan of treatment. If more than one diagnosis is treated concurrently, enter the diagnosis
that represents the most acute condition and requires the most intensive services.
Q: The patient has a BKA. The wound is healed and the patient is recertified for PT only, to fit a
prostheses and provide gait training. Would the primary diagnosis change since the wound is
healed?
A: Yes. Since the wound is healed, the patient could not be recertified using the diagnosis of a
complicated wound.
Q: We cannot use listed Secondary Diagnoses as a Primary Diagnoses according to Federal
Register. However, can we use listed Primary Diagnoses as Secondary Diagnoses?
A: Yes, but be aware primary diagnosis is the key variable in assignment to relevant case mix
groups.
Q: If a therapist visits the patient to perform wound care exclusively (no traditional therapy
services), will those visits contribute to the 10 visits needed for credit in the service utilization
dimension in the HHRG?
A: If wound care falls within the auspice of your state practice act for physical therapists, they
may provide the specific type of wound care services defined in their state practice act. Such
visits in this specific situation can be billed as physical therapy visits and will count toward the
therapy threshold. Medically unnecessary visits for therapy care will be subject to medical
review regardless of what type of practitioner furnishes the excess treatment.
Q: If a patient has a closed healed, surgical wound, do you still consider it a "wound" on the
OASIS assessment?
A: At M0482, Does this patient have a surgical wound? - the response would be No if the wound
is healed and not considered current. Old surgical wounds that have resulted in scar or keloid
formation are not considered current surgical wounds.
Q: On all of the ADL OASIS questions, do you answer them with "safely" as an assumed part of
the criteria? Patients can often do things, but not safely. How do you properly assess them in that
case?
A: The OASIS Item-by-Item Tips for M0660, M0670, M0680, M0690, M0700 have been
revised to include reference to safety as a criterion in assessing ADL dependency. The revised
Chapter 8 Item-by-Item tips will be available on the OASIS web site in the near future.
Q: When assessing "bathing", often people are being bathed on the commode or in bed because
they don't have the right equipment for a tub bath. Do we assess them at what they ARE doing or
what they COULD do with the right equipment?
A: The assessment should be based on the patient's ability with the right equipment.
Q: On OASIS question M0250, if the nurse gave the last IV dose on the discharge visit, does she
still check box 1 on the OASIS discharge?
A: Yes.
Q: On OASIS question 380B1 Caregiver Summary, it asks for the type of assistance that is given
by the primary caregiver. Should this include only the care that they themselves give or include
the care that they have organized others to do for them?
A: The response to this item should include only the care given by the primary caregiver
him/herself.
Q: Is it always incorrect to use a manifestation of a disease process as a primary diagnosis on the
485, OASIS, and UB-92? The Home Health PPS Final Rule indicated that certain manifestations
can never be listed as the primary diagnosis. It sounded like it is no longer correct to make the
primary diagnosis "the one that drives the visits." For example, the patient is being treated for
urinary retention but multiple sclerosis or cerebrovascular accident is the disease process
responsible. Would coding MS or CVA be seen as upcoding?
A: The primary diagnosis should be determined according to official policies that have been
developed over the years by Medicare and its fiscal intermediaries for home health, except when
ICD-9-CM coding sequencing requirements take precedent. The instructions on manifestation
codes in the PPS Final Rule were not intended to pertain to all possible instances where a direct
cause of the need for home care is traceable to an underlying disease process. ICD-9-CM
sequencing requirements for manifestation codes are indicated in the index to diseases where two
codes are listed after a specific condition and the second code is in brackets. They are also
indicated in the tabular list where codes appear in italicized letters. Codes that are italicized in
the tabular list can never appear in the primary diagnosis field, and must be preceded by the code
for the underlying condition. When using the index to code diagnoses, certain conditions are
properly coded by specific pairs of diagnoses in the order given. One case that has come to our
attention is the coding of diabetic ulcers. In the index to diseases of the ICD-9-CM, diabetic
ulcers is listed under: ulcer, diabetic (mellitus) 250.8 [707.9]. The code in brackets must be listed
after the underlying condition. Therefore, the correct diagnosis coding is code 250.8x, "Diabetes
with other specified manifestations", in the primary diagnosis field, followed by a chronic ulcer
code from category 707, which would be the specified manifestation. It is incorrect to use 250.8x
if it is not followed by an additional code to identify the manifestation. In summary, unless ICD9-CM provides a clear justification for an alternative to the traditional Medicare diagnosis
reporting conventions, the agency should continue to code as primary the diagnosis most related
to the plan of care. In addition, the primary diagnosis must be acceptable on OASIS (i.e.,
surgical, E-codes, and V-codes are not allowed). Consult the home health agency manual for
information on how to determine the primary and other diagnoses.
With the type of patient that seems to be envisioned in the question, traditional Medicare coding
practice would be to use urinary retention as the primary diagnosis. This diagnosis is not affected
by manifestation code sequencing requirements. Therefore, coding CVA or MS would be
incorrect.
Q: If a RAP is cancelled and resubmitted because therapy visits do go over 10, must you correct
the OASIS document where you answered "No" to M0825?
A: If there is a change in the patient's plan of treatment that requires more therapy visits than
projected, another follow-up assessment (RFA #5) is expected to provide the current assessment
and need for additional therapy visits. This is in keeping with the regulation at CFR 484.20 (b)
Accuracy of encoded data: The OASIS assessment must accurately reflect the patient's status at
the time of the assessment. It is necessary to have one consistent document for the patient's
assessment, so if therapy visits are increased there should be concurrent OASIS and clinical
record documentation.
Q: What are HHA's options if they originally answered "No" to M0825 but subsequently
performed 10 or more patient visits? Can they cancel the RAP that they originally filed or must
they submit a SCIC?
A: If there is a change in the patient's plan of treatment that requires more therapy visits than
projected, another follow-up assessment (RFA #5) is expected to provide the current assessment
and need for additional therapy visits. This is in keeping with the regulation at CFR 484.20 (b)
Accuracy of encoded data: The OASIS assessment must accurately reflect the patient's status at
the time of the assessment. It is necessary to have one consistent document for the patient's
assessment, so if therapy visits are increased there should be concurrent OASIS and clinical
record documentation.
If, however, this was a simple data entry error, it would still be necessary to make the
corresponding correction to the OASIS submission. As this is a non-key field correction,
agencies can make this change in their files and retransmit the corrected assessment. HHAs
should refer to page 29-30 of the OASIS Program Instructions (file 99-2.65 available on the
OASIS website at http://www.hcfa.gov/medicaid/oasis/hhregs.htm) for more information on the
current OASIS correction policies.
If the OASIS indicates there has been a significant change in condition, a SCIC may be claimed.
Alternatively, if there has not been, but the therapy threshold has been passed, the RAP should
be cancelled and resubmitted with the corrected HIPPS code.
Q: We are aware that 10 or more therapy visits within a 60-day episode presents an increase in
the grouper. If a therapy assistant provides a portion of the required visits, then do we still
qualify for the higher grouper?
A: Yes, in accordance with existing policy you would still qualify for the higher HHRG. As
stated on page 41155 of the HH PPS Final Rule, we do not believe that any changes to the
current coverage rules governing the coverage of physical therapy, occupational therapy, and
speech-language pathology services under the Medicare home health benefit is warranted at this
time. If we believe coverage revisions are necessary for future refinements to the HHA PPS, we
may consider revisiting the coverage guidelines at that later time. Under the case mix
methodology, patients with intense therapeutic needs are classified in higher payment groups. A
physical therapist, occupational therapist or speech-language pathologist would have to diagnose
the therapeutic needs of the patient. If significant assistant substitution occurs under PPS, we
may focus medical review efforts or re-price the case-mix groups.
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LUPA:
Q: Can the 4 visits that constitute a LUPA be a combination of any services? They don't have to
be all one service do they?
A: LUPA visits can be in any combination. One qualifying skilled visit is required for Medicare
home health eligibility during the episode.
Q: If the physician orders 4 or fewer visits, I know the episode will be paid the LUPA amount.
Can I still submit a RAP?
A: Yes. The agency has the option of submitting either a LUPA claim with no corresponding
RAP or a RAP which would require a payment adjustment after the agency submits the claim
containing the actual number of visits provided.
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Hospice:
Q: Can a hospice patient receive home health services for a reason unrelated to their election of
hospice?
A: Yes. PPS does not change the current rules that permit a hospice patient to receive home
health services for a condition unrelated to his/her reason for hospice election.
Q: NAHC believes that there is an error in the Federal Register notice for HHPPS and the HCFA
web site Q&A dated September 2, 2000 regarding the statement that once a beneficiary elects the
hospice benefit they no longer qualify for home health services. According to 42 CFR 418.24:
"(d) Waiver of other benefits. For the duration of an election of hospice care, an individual
waives all rights to Medicare payments for the following services … (2) Any Medicare
services that are related to the treatment of the terminal condition for which hospice care was
elected or a related condition…."
To date Medicare beneficiaries have not been required to waive other benefits when service
needs are unrelated to the terminal illness. These beneficiaries have always qualified for home
health services for unrelated needs. For example, a person electing hospice care for terminal
cancer may need home health care services for their diabetic condition. Please clarify this issue.
A: The question from the web site and the response to public comment in the Federal Register
are correct but need clarification. As long as the need for home health care is unrelated to the
reason the patient was admitted to hospice care, the patient may still qualify for home health
services.
Q: If a patient transfers to a hospice during an episode, does the agency get a PEP or a full
payment? What if the hospice and home health agency are under common ownership?
A: Please refer to page 41144 of the final rule dated July 3, 2000 where we state, "If a patient
elects hospice before the end of the episode and the patient did not experience an intervening
event of discharge and return to the same HHA, or transfer to another HHA during an open 60day episode prior to the hospice election, the HHA receives a full episode payment for that
patient. Upon hospice election, the beneficiary is no longer eligible for the home health benefit.
The common ownership restriction for the PEP adjustment applies only to the relationship
between two HHAs providing covered home health services to a home health eligible
beneficiary."
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HIPPS Coding:
Q: My understanding is that when the HRG is translated to the HIPPS code, the 5th position of
the HIPPS code indicates whether the payment code was "calculated " on supplied information
or "derived" from default values from some combination of the 3 domains. However, States will
not be accepting any OASIS that is not completely filled out. The HAVEN software (provided
by HCFA) does not allow any portion of the OASIS to be left unanswered. But non-Haven
vendor software will allow this.
A: The state system does not reject records based on the 5th position of the HIPPS code. The
HIPPS 5th position can be either 1 or 2 for an assessment that passes all fatal error checks. An
OASIS record that clears all of the state's fatal error checks logically cannot have a HIPPS 5th
position other than 1 or 2, not because the state will reject the record based on HIPPS code but
because any error that would cause the HIPPS 5th digit (calculated by the grouper.dll) to be 3-7
would cause the record to fail at least one fatal error check. If the grouper algorithm used by the
HHA's software is faulty, it could return a HIPPS code other than 1 or 2 without any fatal errors,
and the agency would only receive a warning that the submitted HIPPS and calculated HIPPS
did not match. Similarly, HAVEN will not export assessments with fatal errors, so the HIPPS 5th
position for any assessment exported from HAVEN must be either 1 or 2.
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Wage Index:
Q: Why does an agency in an urban area that services the rural areas receive a different payment
for patients versus patients located in the urban area?
A: The labor adjustment to the PPS rates is based on the site of service of the beneficiary. The
beneficiary's location is the determining factor of the labor adjustment. The location of the
agency does not determine the labor adjustment. Site of service was Congressionally endorsed
because of a pattern of historical abuse of wage index adjustment based on agency location.
Q: I thought the wage index was tied to the hospital wage index and yet in my State the hospital
wage index is slightly higher. Why?
A: The pre-floor and pre-reclassified hospital wage index is used to adjust the labor portion of
the home health PPS rates. The hospital wage index is adjusted to account the geographic
reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the
Social Security Act. This section of the Statute says that hospitals in certain rural counties
adjacent to one or more Metropolitan Statistical Areas (MSAs) are considered to be located in
one of the adjacent areas MSAs if certain standards are met. According to law, the Medicare
Geographic Classification Review Board considers application by hospitals for geographic
reclassification for purposes of payment under the hospital prospective payment system.
According to the law, geographic reclassification applies only to hospitals. Additionally, the
hospital wage index has hospital specific floors that are required by law. Because these floors do
not apply to home health agencies, it was necessary to use the pre-floor data. Since we use the
pre-floor and pre-reclassified hospital wage index, it varies slightly from the numbers published
in the inpatient hospital PPS regulation that reflects the reclassification and floor adjustments.
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Medical Review:
Q: In the Pacific NW we tend to have fewer visits per patient now. It has been said that FIs will
be doing close scrutiny of episodes with 5 to 15 visits - our averages fall about 13 visits per
patient NOW - will we be subject to closer medical compliance scrutiny? Will our historical
numbers be taken into account?
A: With the change in payment methodology for home health services to a prospective payment
system the potential vulnerabilities to the Medicare program have also changed. At this moment,
HCFA recognizes that current data analysis is not sufficient to identify provider/service specific
vulnerabilities. Consequently, RHHIs have been instructed to concentrate their efforts on
potential vulnerabilities identified as inherent to the PPS payment methodology. Agencies
providing inappropriate visits (not reasonable and necessary) in order to reach the LUPA and/or
therapy thresholds (4 and 10 visits respectively) in order to receive the full episode payment is
one identified vulnerability. However, this is only one of the areas that RHHIs will be targeting,
and they will be taking into account an individual agency's past and current performance when
deciding how to concentrate their medical review efforts.
Q: We are all trying to do our best! When will the fraud and abuse dogs be called off so we can
work together instead of adversarial?
A: HCFA strongly believes the majority of Medicare providers are honest and hardworking. It is
the goal of medical review to pay claims correctly. HCFA can achieve this goal by identifying
payment errors and educating providers based on the findings. This is especially important when
implementing a new payment methodology such as the prospective payment system. By
identifying errors and working together with RHHIs and HHAs to educate providers, we will
best be able to protect the Medicare program and ensure its existence well into the future.
Examples of our recent provider outreach activities include weekly conference calls with the
industry, extensive provider education by the RHHIs and the HH PPS website.
Q: You called the PPS a system of averages. Why then does what we heard about expected
medical review focus on above average payments related to services provided? For every
episode an agency profits from and is medical reviewed should we not review episode of loss?
A: In addition to targeted review on areas of potential vulnerability, the medical review strategy
for HH PPS also includes a level of random review. Random review means that every claim
submitted to a RHHI has equal chance of being subjected to medical review, regardless of type
of service provided, utilization or cost of the claim. The goal of medical review is to pay claims
correctly and to ensure that HHAs are being reimbursed appropriately for the services provided
under PPS.
Q: Describe what you have referred to as large scale monitoring by provider of their
reimbursement? What are you concerned about?
A: You are probably referring to our large-scale effort to monitor HH PPS. This monitoring is
directed at addressing a number of concerns. For example, the GAO has expressed concern in
two reports that agencies will tend to underserve patients, maximize payments and thus reap
windfall profits. We are also planning to monitor several issues which were the subject of
concern in public comment, with an eye to future revisions to improve the system, such as the
correct LUPA threshold and the use of minutes rather than hours for the therapy threshold.
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Cost Reporting:
Q: When will Medicare Cost Report forms and instructions be released?
A: Both the cost report forms and the instructions should be available by March 2001.
Q: Please explain how cost reporting will work under PPS. Will we have a cost report for
everything ending on 9/30, or will we have a blended cost report that will end up not reimbursing
our full cost under IPS?
A: You should file your cost report according to your normal fiscal year end date. The cost report
will show a statistical break, where necessary and applicable, between IPS (cost reimbursement)
and non-IPS (PPS). The settlement summary (worksheet S) will include both IPS and non-IPS
settlement amounts.
Q: How will unduplicated census be calculated for Medicare cost reports for the time period 1/1 9/30 related to IPS cost report calculations?
A: The unduplicated census will be calculated the way it is currently calculated but for the period
ending September 30, 2000. That is, the number if unduplicated beneficiaries serviced through
and including September 30, 2000 must be included on proposed worksheet S-3, part I, column
2, lines 10 & 10.01. Additionally, the number if unduplicated beneficiaries serviced on or after
October 1, 2000 must be included on proposed - worksheet S-3, part I, column 2, lines 10 &
10.02. Beneficiaries serviced on or after October 1, 2000 may also be counted in the pre
10/1/2000 beneficiary count if they received services during this period. In summary, the
beneficiary counts for pre 10/1/2000 and post 9/30/2000 are not mutually exclusive.
Exhibit 1: Partial depiction of the proposed Worksheet S-3, Part I
line 10 - Unduplicated census count - full cost reporting period
line 10.01 - Unduplicated census count - pre 10/1/2000
line 10.02 - Unduplicated census count - post 9/30/2000
Q: On page 41159, the Federal Register reads, "...we would like to make the new system
independent of the burdensome and idiosyncratic cost finding process of the previous, reasonable
cost-based payment system." yet on page 41167 it says," Cost reporting requirements will not
end with PPS." How can both of these statements be true?
A: The new payment system is not based on cost settlement data. However, cost reports will be
required to refine the rates in the future.
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Miscellaneous:
Q: On page 41149 (bottom of second column) of the Final Rule, it states that "the final payment
may increase or decrease in response to a difference between the therapy projected at the start of
care and the therapy received by the patient by the end of the 60-day episode." Officials from
two RHHI's who spoke at the "First Word on the PPS Final Rule" clearly indicated that their
systems were being developed to review the actual therapy usage and decrease payment, if
warranted. They said they would not increase payment if actual therapy exceeded the threshold if
the RAP was submitted assuming it would be below the threshold. Do you stand by the response
in the Final Rule or has your position changed?
A: The final rule speaks to the issue from a conceptual rather than operational perspective.
Agencies whose HHRG needs to be changed because of an increase of necessary therapy to a
level above the threshold may cancel and resubmit a RAP at the correct level to receive a higher
payment.
Q: How do we handle the situation where we have submitted a claim and later learn that a
change needs to be made to it? For example, late visits are received that are covered by a signed
physician's order? Or, a visit was included that should not have been?
A: Providers may cancel and resubmit claims in accordance with current rules.
Q: How do we get the HIM-11 revision "How to do billing under PPS"?
A: The latest Home Health Manual is available online at
http://www.hcfa.gov/pubforms/progman.htm. There are updates to this revision at
http://www.hcfa.gov/pubforms/transmit/transmittals/comm_date_dsc.htm.
Q: Would HCFA consider a listserv format for PPS questions and answers across the nation with
FIs as subscribers?
A: There is a listserv (hh_pps_l), which you can subscribe to at
http://www.hcfa.gov/medlearn/mailists.htm. It is used for announcements about PPS
implementation.
Q: Since licensed staff other than the supervisor/providing professional (e.g. intake staff) take
verbal orders and must sign and date those orders, will countersignature of such orders by the
supervisor/providing professional suffice to meet the "attestation" reference in the final rule?
A: Yes. A countersignature of the supervisor/providing professional will suffice to meet that
requirement.
Q: If a patient moves to another SMSA during the episode, which SMSA is indicated on the final
claim?
A: The SMSA that the patient moved to is the one that is supposed to be used on the final claim.
The MSA or non-MSA at the end of the episode is used.
Q: When PPS for Skilled Nursing Facilities was instituted, HCFA calculated and created a PPS
rate sheet for each individual SNF showing each of the RUG categories and the associated
payment classification. Will HCFA be doing the same thing for home health agencies under
PPS?
A: No, there is an agency specific component in the SNF PPS. HH PPS does not have an agency
specific component.
Q: How is Outpatient Part B home health handled under PPS?
A: It depends on whether or not the patient is under a home health plan of care. If the patient is
under a plan of care, the outpatient therapy is bundled into the prospective payment rate. If the
patient is not under a plan of care, the HHA is supplying the therapy to the patient outside the
Medicare home health benefit and it is not subject to HH PPS.
Q: If a doctor changes a medication dosage on Day 59, does the agency have to get a signature
on this verbal order BEFORE they can submit the final claim? Are they required to get signature
on all interim orders or just the 485 before they can submit the final claim?
A: PPS does not change the current countersignature requirements. Claims can be submitted
when existing countersignature requirements are met.
Q: HCFA is prohibited by law from making outlier payments in excess of 5% of total projected
HH PPS outlays for the year. What plans have you made to address the possibility that those
funds may be exhausted mid year?
A: As stated on page 41160 of the HH PPS Final Rule, "the 5 percent constraint applies to
estimated total payments, not actual total payments. Each year, we will establish the loss-sharing
ratio and the fixed dollar loss values that will be used throughout the next fiscal year to calculate
outlier payments. There will be no reconciliation of actual outlier payments to the 5 percent
target either during a current fiscal year or in any subsequent fiscal years. If actual outlier
payments during a given year exceed 5 percent of actual total payments, there will be no attempt
to recoup the difference. Similarly, if total outlier payments in a year fall short of 5 percent of
actual total payments, there will be no additional payments made to agencies. Such information
will, however, be part of the analysis conducted for setting the appropriate threshold in
subsequent years."
Q: What is the reason for an "affirmation" letter that acknowledges base payments for all RAPs
until HCFA's software system is ready, and, more importantly, is it true that without submitting
the letter, no RAP payments will be made? Why?
A: Providers must sign and submit the "affirmation" letter in order to acknowledge that we are
giving them special payments and to acknowledge that recovery of any overpayments will be
made by withholding 100 percent from Medicare home health payments, that recovery of all
payments is to be completed within 90 days from the date that HH PPS systems are fully
operational, and that the provider will make a good faith effort to assure that recovery is made
within that time frame. An original signed statement must be received before any special
payments can be released.The statement must be signed by an official of the provider who is
legally authorized to commit the provider to repayment of these special payments: that is, the
administrator, chief executive officer, chief operating officer, or chief financial officer. A copy
of the letter is available at http://www.hcfa.gov/pubforms/transmit/A0059.pdf on page 11
(Attachment 2). A provider may E-mail or fax a copy of its request ahead of the original
document to facilitate the initiation and preparation of the special payment. However, an
intermediary you may not make any special payments to a provider that has not submitted an
original acknowledgement letter.
Q: A patient lives alone and is being treated by the HHA for wound care. The patient wants to go
across town to stay with her daughter for a week or so, the daughter had been trained by the
home health agency to do the wound care. The HHA will not be seeing the patient during this
time frame. Is the patient's homebound status is called into question here. How would PPS work?
Would the patient be discharged when she goes to the daughter's house (PEP adjustment?).
When she returns would the HHA start a new episode? Or, would the HHA put the patient on
"hold" (without any official transfers or resumptions of care) and continue on with the care
without regard to this break in the action?
A: A patient who is under a home health plan of care and changes her home location during an
episode of care will still be considered homebound as long as the patient continues to meet the
definition of homebound as stipulated in the HIM-11 section 204.1 "Confined to the Home". The
Patient's place of residence must comply with the HIM-11204.1 (B), which stipulates a patient's
residence is wherever he/she makes his/her home. This may be may be his/her own dwelling, an
apartment or a relative's home.
When a patient who is under a home health plan of care requires a temporary "on hold for
agency services", that patient will remain in the same 60 day PPS episode upon returning to the
agency unless of course the patient's return is not within the 60 day episode of care time frame. If
the patient returns to the agency after the 60-day episode time frame, the patient will need to be
discharged by the agency and then re-admitted. The agency must provide the documentation to
support the "on hold status", which would include a MD order which reflects the exact dates of
the holding because the patient plan of care will be on hold. The agency must reflect in its
documentation how the patient's needs will be met while the patient is on hold. When the patient
returns to the agency the agency must have a MD order reflecting that the patient plan of care is
resuming and the effective date.
Q: The traditional way of documenting frequency and duration of home health services has been
to reflect the number of visits each day/week/month followed by the duration. Is it permissible
for HHAs to delete the reference to day/week/month, thereby reflecting only the number of visits
in the episode? Example: Nursing visits 10x60 days.
A: HHPPS does not change this requirement. Section 234.7 of the HIM-11 states, "Frequency
denotes the number of visits per discipline to be rendered, stated in days, weeks, or months.
Duration identifies the length of time the services are to be rendered and may be expressed in
days, weeks, or months."
Q: How will a rate increase for next year be implemented? Prorated between overlapping
episodes on October 1, 2001? Effective for all new episodes beginning on and after October 1,
2001? Or effective for all episodes ending on or after October 1, 2001?
A: The end date of the episode determines the year and rate level at which the claim will be paid.
Q: HHA software vendors are creating their own grouper software to match the HCFA grouper
software. Many HHAs will be reliant upon these software vendors for accuracy of the output
needed for billing. What responsibility do vendors and HHAs have over the accuracy of this
output?
A: Medicare has a provider agreement with the HHA and necessarily holds the HHA responsible
for RAPs and claims submitted to Medicare for payment of covered services.