November 2012 HH & Hospice Regulatory Review. Presented by: Deanna Loftus Director of Regulatory Compliance

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1 November 2012 HH & Hospice Regulatory Review Presented by: Deanna Loftus Director of Regulatory Compliance

2 Webinar Agenda Medicare Administrative Contractors Preparing for ICD-10 Hospice Quality Reporting Home Health Rates/Grouper Therapy Relief?? F2F Relief Alternative Sanctions CAHPS Future Trends

3 MEDICARE ADMINISTRATIVE CONTRACTORS

4 Home Health & Hospice Jurisdictions Medicare currently has four Jurisdictions assigned for Home Health and Hospice Administrative Contractors. Jurisdictions A D are reserved from the HH & H workloads. A map of the regions can be found at: MAP.pdf It is important for your agency to be up to date with the instructions from your contractor. So make sure you are signed up for their newsletters and alerts. You can find links to each of the contractors at the HEALTHCAREfirst regulatory blog.

5 Palmetto GBA Claim Processing Issues Log tto/providers.nsf/docscat/jurisdictio n%2011%20home%20health%20and %20Hospice~Resources~Tools%20and %20Calculators~Home%20Health%20 and%20hospice%20claims%20proces sing%20issues%20log?

6 Claim Processing Issues Log National Government Services %20XVIII%20Providers&LOB=Home%20Health%20and%20Hospice&savecookie=no (not all issues are listed here)

7 Claim Processing Issues Log Medicare NHIC (not all issues are listed here)

8 Claim Processing Issues Log CGS (not all issues are listed here)

9 ICD

10 ICD-10 Changes Move from about 13K to 68K ICD-9 codes are mostly numeric and have 3 to 5 digits. ICD-10 codes are alphanumeric and contain 3 to 7 characters. ICD-10 is more robust and descriptive with oneto-many matches in some instances. ICD-10 codes will be updated every year, same as the ICD-9 were.

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12 ICD -10 Files Tabular and index of ICD-10-CM Addenda (changes since the 2012 version) Complete list of ICD-10-CM code titles long and abbreviated General Equivalence Mappings Reimbursement Mappings Duplicate ICD-9-CM and ICD-10-CM codes

13 HOSPICE QUALITY REPORTING Reporting/

14 Hospice Quality Reporting Structural Measure / QAPI Measure NQF #0209 / Pain Measure Series-Part-4-Quality-Data-Reporting

15 CY 2013 Final Rule Measures

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17 2013 PPS HH REFINEMENTS & RATE UPDATE

18 Grouper Changes CMS is revising the grouper logic to award points when fracture codes in the payment diagnosis field are paired with v-codes in either the primary or secondary diagnosis fields.

19 Outlier Changes FDL ratio is being revised from 0.67 to 0.45 for CY 2013.

20 2012 vs Payment Rates 2.3 percent market basket index inflation update Reduction of market basket update by one percentage point and a 1.32% case mix creep Base Rate / Rural Base Rate 2013 Base Rate / Rural Base Rate $ / $ $2, / $ *note a 2% reduction to these rates when not submitting quality data

21 2012 vs Discipline Rates Discipline 2012 Non-Rural / Rural 2013 Non-Rural / Rural HHA $51.13 / $52.66 $51.79/ $53.34 MSS $ / $ $183.31/ $ OT $ / $ $125.88/ $ PT $ / $ $125.03/ $ SN $ / $ $114.35/ $ SLP $ / $ $ / $ *note a 2% reduction to these rates when not submitting quality data

22 2012 vs Supply Rates Non-Routine Supply Rates (NRS) *note a 2% reduction to these rates when not submitting quality data Severity Level 2012Non-Rural/ Rural 2013 Non-Rural/ Rural 1 $14.37 / $14.81 $14.56 / $ $51.91 / $53.46 $52.58 / $ $ / $ $144.16/ $ $ / $ $214.19/ $ $ / $ $330.29/ $ $ / $ $568.06/ $585.11

23 2012 vs LUPA Rates LUPA Add-On Rates 2012 Non-Rural/ Rural 2013 Non-Rural / Rural $94.62/ $97.46 $95.85 / $98.73 *note a 2% reduction to these rates when not submitting quality data

24 F2FRelief F2F document titling can be non-prescriptive to prevent inappropriate claim denials based solely on the document label. Non-physician practitioners in inpatient settings are allowed to perform the encounter and inform the certifying physician. Payment/HomeHealthPPS/Downloads/QandAsFull-revised pdf

25 Therapy Changes

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27 Therapy Relief In cases where the patient is receiving more than one type of therapy, the qualified therapists must complete their reassessment visits during the 11th, 12th, or 13th visit for the required 13th visit reassessment and the 17th, 18th, or 19th visit for the required 19th visit reassessment. Exceptions due to frequency/modality

28 Therapy Relief In the case of a qualified therapist missing a reassessment visit, therapy coverage resumes with the visit DURINGwhich the qualified therapist completes the late reassessment, instead of the visit after the therapist completes the late reassessment.

29 Therapy Relief When multiple therapy disciplines are involved and the required reassessment visit is missed by one of the therapy disciplines providing service but not the others: therapy coverage continues for the therapies that did complete the re-assessment and only cease for the particular therapy discipline that did not complete timely.

30 CMS Scenario for Multiple Therapy Example:

31 2012 Therapy and NC Charges Example:

32 Therapy and NC Charges Cont. Example:

33 Therapy and NC Charges Cont. Example:

34 Additional Clarifications Needed Is it safe to assume based on the example provided on page 124 of the final rule that Single Therapy situations now have the 13 th visit marked as non-covered if therapy is missed? What happens to compliance if visits are denied on medical review? Will the Therapy FAQ s be updated

35 STAY IN COMPLIANCE!!!!! Make sure you utilize all tools available to you in tracking Therapy visits Follow-up with your therapists Review your current process for holes

36 Alternative Sanctions Whether the deficiencies pose immediate jeopardy to patient health and safety. The nature, incidence, degree, manner, and duration of the deficiencies or noncompliance. The presence of repeat deficiencies, the HHA s compliance history in general, and specifically with reference to the cited deficiencies, and any history of repeat deficiencies at either the parent or branch location

37 Alternative Sanctions Cont. Whether the deficiencies are directly related to a failure to provide quality patient care. Whether the HHA is part of a larger organization with documented performance problems. Whether the deficiencies indicate a system wide failure of providing quality care.

38 HHCAHPS Home Health Compare

39 Other Items around the corner OASIS C-1 Revisions centered around the switch to ICD-10 coding. Sequestration?? PECOS

40 PECOSEdits Claim denials for services referred by nonenrolled physicians are expected to begin soon CMS promises to give 60 day notice prior to turning edits on

41 PECOSEdit: Reason Code Statement From date on the claim is on or after the date the phase 2 edits are turned on. Type of bill is '32' or '33' Covered charges or provider reimbursement is > 0, but attending physician NPI on the claim is not present in the eligible attending physician file from PECOS OR the attending physician NPI on the claim is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from PECOS OR the specialty code is not a valid eligible code

42 PECOSEdits Reason Code 37237: Statement From date on the claim is on or after the date the phase 2 edits are turned on. TOB is '32' or '33' TOB frequency code is '7' or 'F-P' Covered charges or provider reimbursement is > 0, but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claims is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from PECOS or the specialty code is not a valid eligible code

43 Items on the Horizon New Conditions of participation Home Health Co-Pays Episode Caps Elections over what s next

44 STAY IN THE LOOP

45 Thank you! For the latest Regulatory News & Updates, visit HEALTHCAREfirst s Regulatory Blog at For more information about HEALTHCAREfirst, please visit our website or call