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2011 PPS UpdatesEfficiencies Ensure Jungle SurvivalMissouri Alliance for Home CareAnnual ConferencePatricia W. Tulloch RN, BSN, MSN, HCS-D, Senior Consultant,RBC Limited Healthcare & Management ConsultantsP: 845-889-8128 E: [email protected] www.rbclimited.comIntegrated OASIS Solutions RBC Limited 2011ObjectivesProvide a critical review of the diverse 2011 PPSinitiatives;Detail the 2011 PPS changes that impact currentagency processes and outcomes;Identify Best Practices that meet the challenges of the2011 PPS revisions, including therapy requirementsand associated documentation needs;Discuss agency strategies to ensure effectiveintegration of the 2011 PPS updates.Integrated OASIS Solutions 2 RBC Limited 2011RBC Page 1 of 44

Another Adventurous YearPPS UpdatesG Code UpdatesWhat Next?Integrated OASIS Solutions 3 RBC Limited 2011Agency EfficienciesLean To ProgramsEfficiency Priorities: 2011 PPS UpdatesC ca Efficiencies:Clinicalc e c es: OASISO S S Visits;V s ts; Coding;Cod g; Referrals;e e a s; OtherOt eEliminate Redundancies: Oversight & Process; AuditsRefine Roles and OutcomesGlobal Operational ReviewsIdentify & Merge ProcessesModify RolesProcess ModificationsInfrastructure SupportsAccountability CulturesSecond Peel: More to ComeIntegrated OASIS Solutions 4 RBC Limited 2011RBC Page 2 of 44

Easy Money for CMSCompliance IssuesOrders; RAPS’s & Final ClaimsF2F; Physician signatures & dates; Therapy Reassessments & SupervisionsCoP sCoP’sTimeliness; DRR; Physician orders; OASISSurvey IssuesCare PlanningAddresses every identified risk or potential riskLook Back DocumentationHave you implemented the POC?Audit IssuesOASIS-C supports medical necessity & servicesOASIS-C supports therapy utilizationConsistent clinical documentation Quality & Reimbursement Issues: More To ComeIntegrated OASIS Solutions 5 RBC Limited 2011HCR (ACA) Paves the WayConsumer is KingMedicare Pilots DetailedACO’sBundlingMedical HomesMedicare Value Based Purchasing (P4P)Physician Engagement & AccountabilityFocus on Chronic Care ManagementCMS Center for InnovationEnhanced Fraud and Abuse InitiativesZPICS; Integrity Audits; MAC’s; Heat Teams; RACSIntegrated OASIS Solutions 6 RBC Limited 2011RBC Page 3 of 44

Leadership PrioritiesRegulatoryCompliance processes485’s;85 s; F2F;; Physicianys c a ssignatureg atu e & dates; G Codes; HHABN’sNsVerbal orders; physician communication; therapy documentationOperationalOutcomes Data; Process Best Practices; HH-CAHPSEfficiencies: Clinical & OperationalEpisode Management; Visit UtilizationExpansion: Medicare PPSStrategic Survival in Health Care ReformMarketing; Outreach; Innovation; PartnershipsBe At the Table on Pilot ProgramsIntegrated OASIS Solutions 7 RBC Limited 2011Patient Protection & Affordable Care ActCMS Implementation of New Health Reform ActChanges Physician Certification RequirementsNew Requirement:equ e e t: Faceace to faceace encounterse cou te s foro HH & Hospiceosp ceMarket Basket Provisions1% reduction 2011-20132015: Annual Productivity AdjustmentRebasing Home Health to begin in 2014Phased in thru 2017MedPac to Recommend System to Congress by 2012Section 6405: Claim ChangesCMS Audit for compliance; Enhanced audit initiativesIntegrated OASIS Solutions 8 RBC Limited 2011RBC Page 4 of 44

2011 PPS UpdatesCase Mix CreepCase Mix Diagnoses Changes: To Be Studied in 2011Therapy Services: Assessment & DocumentationPhysician Face to Face (F2) EncountersHH-CAHPSP4POutliers; RuralOtherOwnership; CapitalizationClaim Submissions & CalculationsOversight & Monitoring: Audit InitiativesIntegrated OASIS Solutions 9 RBC Limited 2011Bottom LineCMS Final RuleAffordable Care Act (ACA) Mandates1 popointt reductioneduct o Marketa et Basketas et Indexde2.5% reduction Outlier Budget3.79% Case Mix Creep ReductionNo Action on Case Mix CodesHypertension diagnoses remain case mix in 2011LUPA & NRS Rates not impacted by reductionsMedPac to Recommend Case Mix Model Changesin 2013CMS to Study Hypertension Diagnoses StatusResource utilization in home healthIntegrated OASIS Solutions 10 RBC Limited 2011RBC Page 5 of 44

Future PPS Rate ChangesPPS Re-Basing by 2014 (Maybe Escalated to 2013)CMS to Study Case Mix Weight Changes for 2013Delayed 3.79% 2012 reductions for further studyMedPac to Develop Case Mix Adjustment ModelTo report to Congress in 2013Other ConsiderationsICD-10 October 1, 2013Assessment Tool Changes: CARE Tool?Bundling: 2014Expanded Program Reforms (Pilots: 2012; 2013; 2014)Prevention Models; Chronic Care; Wellness Programs Integrated OASIS Solutions 11 RBC Limited 2011MedPac 2011Reported to Congress 3/2011Five Key Home Health RecommendationsPayment RatesPayment AccuracyPatient SafeguardsBeneficiary Incentives to Control UtilizationProgram IntegrityMedPac DataHH Grows to 11,400 ProvidersMedicare User increased 3.3 millionHome Health is now 9.4% ALL FFS6.5 million episodes; Average 1.9 episodes per userIntegrated OASIS Solutions 12 RBC Limited 2011RBC Page 6 of 44

More on MedPac DataIncrease in number of community referrals64% admissions Community admitted patients36 % admissions Facilityy based referralsLet’s check your current Case Mix ProfileHome Health Margins17.7% All Free StandingFor Profit 18.7% marginNon-profit 14.4% marginAverage Home Health Margins 17.5%Excludes Hospital Home Health -5.4% marginMedPac DataBasis for 2011 Congressional RecommendationsIntegrated OASIS Solutions 13 RBC Limited 2011MedPac RecommendationsPayment Changes: Highest MedPAC HH PriorityEliminate 1% inflation rate in 2012: Freeze ratesAccelerate case mix rebasingg to 2012 ((2 yyear phasepin))Proposed Revise PPS Payment Model: 2013Eliminate Therapy ThresholdsTherapy based on Patient CharacteristicsOther Payment ConsiderationsCost-Sharing: Non Facility Based Beneficiary ReferralsExcludes patients discharged from facilitiesExcludes dually eligibleProposed Home Health Co-Payment 150.00 (per episode)Access Issues for low income beneficiariesMedigap use prohibitedIntegrated OASIS Solutions 14 RBC Limited 2011RBC Page 7 of 44

More on MedPac RecommendationsInstitute Efforts to Address Fraud & AbuseACA details new Fraud & Abuse InitiativesMedPac supports ACA ruleHome Health High Risk Areas: Identify Aberrant CountiesMoratorium on New ProvidersPayment Suspension AuthorityLack of protection for due processPhysician Roles in Home HealthExpandpF2F for all Recertification in 2012Other Audit ConsiderationsRAC Audits Mandated for Medicaid (April, 2011)F2F for Medicaid (April, 2011: State Specific)Mandatory Compliance Programs for ALL ProvidersIntegrated OASIS Solutions 15 RBC Limited 2011Other ACA & PPS UpdatesClaim SubmissionACA: one calendar yearThrough Date on 485PECOS: Enforcement Delayed IndefinitelyDeny payments if MD not on PECOS SystemPhysician Signatures: 1/1/11Sign & Date ALL ordersNo Date StampsClaim Denial: If OASIS not in repositoryRevised HHABN: 4/1/2011 MandatoryCMS Transmittal 361: Change Request 6988Integrated OASIS Solutions 16 RBC Limited 2011RBC Page 8 of 44

Additional Billing RequirementsExpanded G Codes: Implementation: January 1, 2011G0151: Qualified PTG0152: Qualified OTG0153 QQualifiedlifi d SLPG0154: Skilled licensed nurseG0157: PTAG0158: OTAG0159: Maintenance therapy by qualified PTG0160: Maintenance therapy by qualified OTG0161: Maintenance therapy by qualified SLPG0162: Skilled RN for Management & EvaluationG0163: Skilled licensed nurse for Observation & AssessmentG0164: Skilled licensed nurse for Training & N.pdfIntegrated OASIS Solutions 17 RBC Limited 2011Why G Code Changes?CMS Manual System Update 100-20Effective 1/1/11Changeg Requestq7182Additions and Revisions to G CodesMedPAC recommended that CMS improve dataassessment of agencies to ascertain the provisionof unnecessary servicesNeed for more data to differentiate qualified therapistversus a therapy assistantNeed to differentiate skilled nurse for direct servicesversus indirect servicesBottom Line: Data to Direct Medical ReviewIntegrated OASIS Solutions 18 RBC Limited 2011RBC Page 9 of 44

More on G Codes1 G Code per Visit (Final Claim)Reported in 15 minute intervalsSelect G Code that represents the Primary Reason for VisitPrimary Reason for VisitTypically would be the service the clinician spent the mosttimeOn AdmissionNot billNbillablebl unlessl a skilledkill d servicei iis providedid dSelect G Code for the skilled service .pdfCR7182Integrated OASIS Solutions 19 RBC Limited 2011One FAQG Code Use:What is the difference between G0154 SkilledLicensed Nurse and G0164 Skilled licensed nursetraining and education patient or family?CMS intends for home health agencies to use newG codes to report patient/family education andtraining, observation and assessment, andgand evaluation. Reportingpg all othermanagementnursing services (ex: injections, wound care,infusion, catheter changes, etc.) will be reportedwith G0154. What is the primary reason for thisskilled nursing visit?Integrated OASIS Solutions 20 RBC Limited 2011RBC Page 10 of 44

Manual G Code InstructionsIn cases where nursing or therapy provides morethan one service in a visit, the HHA must reportthe G-code which reflects the service for which theclinician spent most of his/her time.Manual Examples:Nursing: Provides both direct care and education.Report the G code that reflects the service the clinicianspent most of their time during that visitTherapy: Performs a therapy service and establishes amaintenance program during the same visit. Reportthe G code which reflects the service for which most ofthe time was spent during that visit.Provide General Staff Guidelines on G Code UseIntegrated OASIS Solutions 21 RBC Limited 2011Maintenance TherapyRestorative Therapy: Based on reasonableexpectation of material improvementException: Maintenance therapy by a qualifiedtherapistDesign an effective maintenance programSpecific to illness or injuryRequires skills of therapistIdentifies program design, instruction, re-evaluationre evaluation409.44 Maintenance TherapyAmount, frequency and duration of services must bereasonableIntegrated OASIS Solutions 22 RBC Limited 2011RBC Page 11 of 44

More on MaintenancePPS Updates Details (Page 124)Maintenance therapy will continued to be covered in theHH settingg when the uniqueq condition off the ppatientrequires complex services, which can only be providedeffectively and safely by a qualified therapist. Themaintenance therapy G codes are defined as provided bya “qualified therapist”.Maintenance therapyRepetitive services are required to maintain function; andrequire the skills and knowledge of a qualified therapistTherapy assistants cannot provide maintenancetherapyIntegrated OASIS Solutions 23 RBC Limited 2011Maintenance ExampleParkinson’s Patient with RARequires services to determine present level of functionand designg pprogramgto maintain capacitypy and tolerancefor treatment. Re-evaluations will occur to assess patientcondition , instruct patient and caregivers on requiredprogram to maintain function.Documentation is CriticalLevel of function & disabilitiesM i tMaintenancegoalslTreatment objectives related to functionCollaboration with physicianBilling G Codes to Designate MaintenanceIntegrated OASIS Solutions 24 RBC Limited 2011RBC Page 12 of 44

Bottom Line on G CodesClinician Education CriticalCMS Benefit Policy Manual: Chapter 7CMSCS Definese es Eachac SSkilleded SeServicev ceDirect; O & A; Maintenance; M & EDocumentation GuidelinesHomeboundReasonable & Medically NecessaryManagement & EvaluationAgency OversightHigh Risk IssuesProactive MonitoringSpecific Clinician FeedbackIntegrated OASIS Solutions 25 RBC Limited 2011Your MAC TransitionsCahaba to CIGNA (Jurisdiction 15)Electronic Notification: 3/11/11 (EFT)CIGNA communicates with all providers ontransitionCMS MedLearn SE1017Other TransitionsNo delays in paymentsNo Complaints in Transition ProcessCIGNA: econferences: 4/19/11 (MAHC)Integrated OASIS Solutions 26 RBC Limited 2011RBC Page 13 of 44

2011 PPS Process ChangesPhysician Face to Face (F2F) EncountersCMS: No further Enforcement DelaysProcessocess ChangesC a gesDocumentationOversightAdditional Education InitiativesTracking/Billing OversightTherapy Services & Clinical DocumentationHH-CAHPS: Report on Home Care Compare 2012OtherClaim Submissions: G Codes & Clinical DocumentationOversight & Monitoring: Audit InitiativesIntegrated OASIS Solutions 27 RBC Limited 2011Face-to-Face (F2F) EncountersACA MandatesPrior to initial certification only for home healthDoes NOT apply to home health re-certificationsPhysician; NP; CNS; PANon physician F2F must be communicated to physician whocertifies patient for home healthHospitalist may perform F2FMust indicate community physician in discharge planPlan must be updated by community physicianF2F TimeframesUp to 90 days prior to the home health SOC ORUp to 30 days after the home health SOCRAP NOT Effected by F2F BUT .Integrated OASIS Solutions 28 RBC Limited 2011RBC Page 14 of 44

F2F DocumentationCMS to Update Medicare ManualPhysician to documentC ca findings(s)Clinicald gs(s) to supposupportt eligibilitye g b tyHomebound StatusNursing or therapy need(s)Physician to sign & date F2F encounter onto thecertification (or Addenda)Documentation must be separate and distinct OR anaddendum to the certificationClearly titled & signed/dated by the physicianNo Standardized Language Allowed for F2FCertification cannot occur byPhysicians NOT registered on PECOSIntegrated OASIS Solutions 29 RBC Limited 2011F2F DocumentationCMS Written GuidanceSpecific clinical documentation findingsNon-physicianp ydocumentation ((NP;; CNS;; PA))Encounter Related to Home CareDocumentation OversightProgram Integrity AuditsAgency responsible only for F2F encounters anddocumentation in certificationPhysician certifying MUST document F2FPatient F2F related to primary reason for Home CareNot to be correlated by diagnosisBilling; Survey Oversight & AuditsMAC Oversight Guidance ; Surveyor OversightIntegrated OASIS Solutions 30 RBC Limited 2011RBC Page 15 of 44

Quick Check on Face to FaceThe facility case manager can complete the Face to Facedocument from the medical record, and have the hospitalistsign and date this document to meet this requirement.TrueFalseIf the patient goes home without the Face to Facedocumentation, the agency must wait to admit this patient.TrueFalsea seThe agency cannot bill the final claim unless the agencyreceives the completed Face to Face documentation.TrueFalseIntegrated OASIS Solutions 31 RBC Limited 2011What’s It Mean to Agency Ops?Where are You With Policies & Protocols for PPS ChangesF2F Encounters: Agency RequirementsAdmission ProtocolsAdmission Packet/Patient Notification MaterialsF2F Encounter Tracking ProtocolsPhysician EducationPhysician Letter/KitOther EducationAgency staff; Contractors; Referral SourcesOversight ProcessesIntegrated OASIS Solutions 32 RBC Limited 2011RBC Page 16 of 44

Patient NotificationsKey ElementsUpdate on new requirements 1/1/11Detail critical elements of new F2F encounterCannot Use Notice of Potential Liability for ChargesIf F2F not documented or does not occur in required timeframeNotice of Non-AcceptanceIf F2F does not occur as indicatedHHABN: Option Box 2 (Updated March 7, 2011)Amend Admission Packet & ProtocolPatient ResponsibilitiesPatient Letter & Face to Face Info Provided on AdmissionIntegrated OASIS Solutions 33 RBC Limited 2011Physician Contact InformationKey ElementsClarity regarding certifying physician role for F2Fencounter and required documentationDetail PPS Final Rule and physician responsibilitiesregarding F2F encounter, care plan, additionaldocumentation requirementsSample F2F Encounter DocumentationOn initial certification (POC or 485) or an addendumto the initial certificationTimingClinical data to support home care needsHome bound status & specific care needsIntegrated OASIS Solutions 34 RBC Limited 2011RBC Page 17 of 44

Referral Sources NeedsKey ElementsPPS Final Rule F2F Encounter RequirementsWho What,Who,What Where,Where When & HowSample Documentation TemplateInclude instructions for patient specific clinical data,homebound status and specific need for intermittent skilledhome health services (nursing, therapy)My Favorite: Assessment; Considerable & TaxingClarify FAQ’sFAQ sProvide simple guideProvide contact data for further discussionOffice visits to key referring sourcesIntegrated OASIS Solutions 35 RBC Limited 2011Staff EducationCan Your Staff Explain the F2F to Physicians &Office Staff?Revised Admission Packet & ProtocolsPatient LetterPatient Education GuidePatient Admission Review ProcessPatient ResponsibilitiesAgency PracticesClinician: Patient Physician AppointmentForm to Physician (Fax & Send in with Patient)Encounter Tracking Protocol: Percent ComplianceNowIntegrated OASIS Solutions 36 RBC Limited 2011RBC Page 18 of 44

Implementation & TrackingSystem AffiliationsCase ManagersDischarge PlannersHospitalists: ElectronicConsiderationsIntakeClinical TrackingMedical RecordsModels485 Trackers/ Face to Face MonitoringWhat Works for You?Integrated OASIS Solutions 37 RBC Limited 2011Bottom Line on Face to FaceAgency Protocols Involve Clinicians from the Get GoFast Fact: Best Practice to Have Patient See Physicianswithin 5-7 days of facility dischargeEngage Physician Office StaffContinue to Tackle from Intake thru AdmissionEducate all referral sources; Simple Format CardAgency DecisionsAd i i withAdmissioni h PhPhysiciani i AAppointmentiClClarityiNAHC DeterminationsLitigation ConsiderationsContinued Lobby EffortsIntegrated OASIS Solutions 38 RBC Limited 2011RBC Page 19 of 44

Therapy PracticesNew Criteria for Home TherapyBenefit DefinedRestoration versus Maintenance TherapyNew Assessment/Reassessment Requirements13th & 19th Visit Qualified TherapistPhysician CollaborationGoal Progress & Rehab PotentialGCCoded AssignmentA it forf FiFinall ClaimCl i BillingBilliCapture Mix of Therapy ProvidersIdentifies Therapy AssistantsM&E; Training & Education; Observation & AssessmentIntegrated OASIS Solutions 39 RBC Limited 2011Best Practices in TherapyRegulations: New PPS 2011 rules requiringfunctional reassessments on the 13th,19th day, atleast every 30 days by a Qualified TherapistAssessments/reassessments: Comparison ofmeasurements in assessing function, effectivenessof therapy, measurable treatment goalsObjective Documentation: Standardized andvalidated toolsCommunication: Between multidisciplinary,paper, EMR, contract and per diem staffScheduling: Ensure 13th & 19th visit by qualifiedtherapistIntegrated OASIS Solutions 40 RBC Limited 2011RBC Page 20 of 44

DocumentationAdhere to Standards of Practice“Notes must reflect progress towards goals, whichincorporate functional assess/reassess which justifymedical necessity.”Functional-assess/reassess 13th, 19th or 30 daysGoals-expectations that condition will improveVariable factors that influence patient conditionObjective-Standardized, and continued need fortherapy to ensure progress to goalsDoes Your Agency have Therapy DocumentationStandards?Integrated OASIS Solutions 41 RBC Limited 2011Therapy Remains an Audit FocusCMS Therapy Focus“Does the Plan of Care for the Medicare paymentperiodi d ffor whichhi h thisthi assessmentt willill defined fi a casemix group, indicate a need for therapy (physical,occupational, or speech) that is reasonable andmedically necessary?”Areas of ConcernOASIS scores supports pport therapytherap utilizationtili ationDiagnosis codes support therapy utilizationVisit notes support therapy Plan of CareAll visits are reasonable and medically necessaryIntegrated OASIS Solutions 42 RBC Limited 2011RBC Page 21 of 44

Therapy DocumentationMUST REFLECTPrior level of functionCurrent deficitsProgres

Manual G Code Instructions In cases where nursing or therapy provides more than one service in a visit, the HHA must report the G-code which reflects the service for which the clinician spent most of his/her time. Manual Examples: Nursing: Provides both direct care and education.