Plant the Seeds of Compliance with PEPPER. Prepared for: WiAHC June 8, Presented by: Caryn Adams, Manager

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1 Plant the Seeds of Compliance with PEPPER Prepared for: June 8, 2017 Presented by: Caryn Adams, Manager

2 Summary and Objectives Program for Evaluating Payment Electronic Report has been available to home health agencies since In the state of Wisconsin, less than 50% of HHAs have accessed their PEPPER reports. If government agencies are able to use this data, shouldn t we also? At the end of this session, the participants will be able to: Verbalize what PEPPER reports are Understand the data collected and reported in the PEPPER reports Effectively utilize PEPPER reports in your agency s compliance plan **Participants may bring their PEPPER reports to review if desired.

3 About the Presenter Caryn Adams, Health Care Manager Caryn is a senior consultant in Wipfli LLP s health care senior living practice. She has more than 25 years of experience in the health care industry. Her vast industry experience lends a deep understanding of the challenges faced by her clients. Caryn is dedicated to providing exceptional client service to assist longterm care, home care, hospice, and senior living providers in achieving their strategic goals.

4 Power Point Presentation

5 W i A H C J u n e 8, Objectives Verbalize what PEPPER reports are Understand the data collected and reported in the PEPPER reports Effectively utilize PEPPER reports in your agency s compliance plan 2 W h a t t h e h e c k i s P E P P E R a n y w a y? Pepper 1

6 PEPPER Program for Evaluating Payment Patterns Electronic Report 4 Summary Summarizes one agency s Medicare claims and compares it with data for the nation, MAC jurisdiction, and the state All providers Targets areas that are vulnerable to improper payments Overpayments and underpayments 5 Purpose Supports CMS s program integrity activities Provides education to providers 6 Pepper 2

7 Purpose Government Accountability Office (GAO) has designated Medicare as a program at high risk for fraud, waste, and abuse. Payments to HHAs have been identified as vulnerable to abuse. OIG has been encouraging providers to develop and implement a compliance program to protect its operations from fraud and abuse. 7 Target Data The Compare Targets Report displays statistics for target areas that have reportable data (11+ target count) in the most recent time period. Percentiles indicate how a home health agency's target area percent/rate compares to the target area percents/rates for all home health agencies in the respective comparison group. For example, if a home health agency's national percentile (see below) is 80.0, 80% of the home health agencies in the nation have a lower percent/rate value than that home health agency. (The home health agency's Medicare Administrative Contractor (MAC) jurisdiction percentile and the state percentile values (if displayed) should be interpreted in the same manner. Percentiles at or above the 80th percentile for any target area indicate that the home health agency may be at a higher risk for improper Medicare payments. The greater the percentile value, in particular the national and/or jurisdiction percentile, the greater the consideration that should be given to that target area. 8 Episode Episode = Claim Part A and Part B claims are eligible for inclusion 9 Pepper 3

8 Average Case Mix Numerator (N): Sum of case mix weight for all episodes paid to the HHA during the report period, excluding LUPAs and PEPs Denominator (D): Count of episodes paid to the HHA during the report period, excluding LUPAs and PEPs Reported as a rate, not a percent 10 Average Number of Episodes N: Count of episodes paid to the HHA D: Count of unique beneficiaries served by the HHA Reported as a rate, not a percent 11 Episodes With Five or Six Visits N: Count of episodes with five or six visits paid to the HHA D: Count of episodes paid to the HHA 12 Pepper 4

9 Non-LUPA Payments N: Count of episodes paid to the HHA that did not have a LUPA payment D: Count of episodes paid to the HHA 13 High Therapy Utilization Episodes N: Count of episodes with 20+ therapy visits paid to the HHA D: Count of episodes paid to the HHA 14 Outlier Payments N: Dollar amount of outlier payments for episodes paid to the HHA D: Dollar amount of total payments for episodes paid to the HHA 15 Pepper 5

10 Reports Organized in three 12 month time periods based on the fiscal year (FY) Summarizes statistics for three fiscal years Distributed in July 2017 Schedule is annually, on or about July 18, Compare An HHA is compared to other HHAs in three comparison groups: State, Medicare Administrative Contractor/Fiscal Intermediary jurisdiction, and nation. These comparisons enable a HHA to determine whether its results differ from other HHAs and whether it is at risk for improper Medicare payments (i.e., is an outlier ). 17 Uses PEPPER can be used to compare its claims data for areas of potential concern and to identify changes in billing practices 18 Pepper 6

11 PEPPER PEPPER determines outliers based on preset control limits. The upper control limit for all target areas is the national 80th percentile. Areas at risk for under coding also have a lower control limit, which is the national 20th percentile. PEPPER draws attention to any findings that are at or above the upper control limit (high outliers) or at the lower control limit (low outliers). 19 Do I Have to Use PEPPER? No Free data You don t have to compile it Why wouldn t you? 20 How to Use PEPPER As a tool for analyzing data, the PEPPER reports provide an opportunity for ongoing process improvement Guides questions to be asked for QAPI 21 Pepper 7

12 What Should I Do When I Get the Report? Do not panic High outlier does not prove anything, but it can prepare you if an audit occurs Determine, if possible, why you are an outlier - Audit a sample of claims - Review the documentation in the medical record - Review the claim: Was it coded and billed appropriately based on documentation in the medical record? Ensure following best practices even if you are not an outlier 22 Use the Resources on the PEPPER Website Share internally Guide auditing and monitoring Multiple facilities Compare and contrast Look for increases or decreases over time Identify root causes of increases or decreases Be proactive and preventive Avoid pay and chase 23 To Be Included: Claim facility type = 3 Include service of home health visits Services must have been provided during the report period Exclude nonpayment and interim claims Final action claim (all disputes and adjustments have been resolved) Medicare claim payment amount >0 Excludes HMO Excludes cancelled claims 24 Pepper 8

13 Also The numerator count needs to be 11 or more 25 Distributed annually in July PEPPER Resources Portal Click on PEPPER Distribution Follow the instructions on the portal Need six-digit CMS certification number (PTAN) Patient control number from a paid claim Need to be the CEO, administrator, president, or compliance officer 27 Pepper 9

14 P E P P E R R E V I E W What Should I Do With the Data? Review outliers Review accuracy of data Review systems and processes QAPI 29 Average Case Mix Risk of over-coding of clinical and functional status OASIS review Documentation to support OASIS education 30 Pepper 10

15 Average Number of Episodes Continuing to treat beyond medical necessity Review documentation Skilled documentation 31 Episodes With Five or Six Visits Using the minimum number of visits to avoid LUPA Review documentation Reasonable and necessary 32 Non-LUPA Payments Same as previous Review documentation Medical necessity Reasonable and necessary 33 Pepper 11

16 High Therapy Utilization Episodes Improper billing for therapy services Review documentation Reasonable and necessary Skilled 34 Outlier Payments Potential over-coding of clinical and functional status Review documentation OASIS review and education 35 Lets Look at a Report Copy of _DMSTR_HHAPEPP_Q4CY15_Provider_D02271.xl s 36 Pepper 12

17 PEPPER 37 PEPPER Pepper 13

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21 49 Q API QAPI Compliance New CoPs More data collection and performance projects Goes into effect in 2018 (if you do not have a current QAPI) 51 Pepper 17

22 Element 1 Design and Scope Ongoing Comprehensive Facility self-assessment tool 52 Element 2 Governance and Leadership 53 Element 3 Feedback, Data Systems, and Monitoring 54 Pepper 18

23 Element 4 Performance Improvement Projects (PIP) 55 Element 5 Systematic Analysis and Systemic Action 56 Root Cause Analysis 57 Pepper 19

24 What Is Root Cause Analysis? Root cause analysis is a method that is used to address a problem or nonconformance in order to get to the root cause of the problem. It is used so we can correct or eliminate the cause and prevent the problem from recurring. Adapted from NASA Root Cause Analysis 58 Philosophy of Root Cause Analysis Each problem is an opportunity because it can tell a story about why and how it occurred It is critical that everyone take a personal and active role in improving quality The true problem must be understood before action is taken To do this well, you must be: Both focused and open-minded Both patient and quick Adapted from NASA Root Cause Analysis 59 What Is Root Cause? Root cause is the fundamental breakdown or failure of a process that, when resolved, prevents a recurrence of the problem Or, in other words: When you fix the root cause, the problem goes away and doesn t come back Root cause analysis is a systematic approach to get to the true root causes of our process problems Adapted from NASA Root Cause Analysis 60 Pepper 20

25 Types of Tools Used in Root Cause Analysis Brainstorming Fishbone diagram Flowchart Whys 61 Plan Do Check Act (PDCA) 62 PDCA PLAN Establish the objectives and processes necessary to deliver results in accordance with the expected target or goals. By establishing output expectations, the completeness and accuracy of the specification are also a part of the targeted improvement. When possible, start on a small scale to test possible effects. 63 Pepper 21

26 PDCA DO Implement the plan, execute the process, make the product. Collect data for charting and analysis in the following CHECK and ACT steps. 64 PDCA CHECK Study the actual results (measured and collected in DO above) and compare against the expected results (targets or goals from the PLAN ) to ascertain any differences. Look for deviation in implementation from the plan and also look for the appropriateness/completeness of the plan to enable the execution (i.e., Do ). Charting data can make it much easier to see trends over several PDCA cycles and in order to convert the collected data into information. Information is what you need for the next step ACT. 65 PDCA ACT Request corrective actions on significant differences between actual and planned results. Analyze the differences to determine their root causes. Determine where to apply changes that will include improvement of the process or product. When a passthrough these four steps does not result in the need to improve, the scope to which PDCA is applied may be refined to plan and improve with more detail in the next iteration of the cycle, or attention needs to be placed on a different stage of the process. 66 Pepper 22

27 Action Steps to QAPI Step 11 Step 11 Getting to the root of the problem Root cause analysis Focuses primarily on systems and processes, not individual performance Teach your staff the process 67 Header In seed time learn, in harvest teach, in winter enjoy. - William Blake 68 Cultivate your craft. Water it daily, pour some tender loving care into it, and watch it grow. Remember that a plant doesn t sprout immediately. Be patient, and know that in life you will reap what you sow. J.B. McG 69 Pepper 23

28 Questions? 70 Contact Information Caryn Adams RN, MSN, RAC-CT, DNS-CT, HCS-O, AHIMA- Approved ICD 10 CM/PCS Trainer Manager, Health Care Practice, Post-Acute Care Pepper 24

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30 Purpose of Home Health Agency Program for Evaluating Payment Patterns Electronic Report Visit PEPPERresources.org Data Report Through Q4CY15 Link to PEPPER Training , Provider D02271 The Program for Evaluating Payment Patterns Electronic Report (PEPPER) summarizes provider-specific data for Medicare services that may be at higher risk for improper Medicare payments. Please refer to the Home Health Agency PEPPER User's Guide at PEPPERresources.org for guidance using the report. If you need assistance, please contact TMF by visiting PEPPERresources.org and clicking on the Help/Contact Us tab. This is HHA PEPPER version Q4CY15 Jurisdiction: Demo Jurisdiction (DMSTR) PEPPER was developed by TMF Health Quality Institute under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services (HHS). Worksheet: Purpose File: Copy of _DMSTR_HHAPEPP_Q4CY15_Provider_D02271.xls

31 Definitions for Home Health Agency PEPPER Target Areas Home Health Target Area Avg Case Mix Home Health Target Area Definition N: sum of case mix weight for all episodes paid to the HHA during the report period, excluding LUPAs (identified by Part A NCH HHA LUPA code) and PEPs (identified as patient discharge status code equal to 06 ) D: count of episodes paid to the HHA during the report period, excluding LUPAs and PEPs Nbr Episodes N: count of episodes paid to the HHA during the report period D: count of unique beneficiaries served by the HHA during the report period 5 or 6 Visits N: count of episodes with 5 or 6 visits paid to the HHA during the report period D: count of episodes paid to the HHA during the report period NonLUPA N: count of episodes paid to the HHA that did not have a LUPA payment during the report period D: count of episodes paid to the HHA during the report period Hi Therapy Utiliz N: count of episodes with 20+ therapy visits paid to the HHA during the report period (first digit of HHRG equal to '5') D: count of episodes paid to the HHA during the report period Outlier N: sum of dollar amount of outlier payments (identified by the amount where Value Code equal to 17 ) for episodes paid to the HHA during the report period D: sum of dollar amount of total payments for episodes paid to the HHA during the report period

32 Home Health Agency PEPPER Visit PEPPERresources.org Compare Targets Report, Four Quarters Ending Q4 CY , Provider D02271 The Compare Targets Report displays statistics for target areas that have reportable data (11+ target count) in the most recent time period. Percentiles indicate how a home health agency's target area percent/rate compares to the target area percents/rates for all home health agencies in the respective comparison group. For example, if a home health agency's national percentile (see below) is 80.0, 80% of the home health agencies in the nation have a lower percent/rate value than that home health agency. The home health agency's Medicare Administrative Contractor (MAC) jurisdiction percentile and the state percentile values (if displayed) should be interpreted in the same manner. Percentiles at or above the 80th percentile for any target area indicate that the home health agency may be at a higher risk for improper Medicare payments. The greater the percentile value, in particular the national and/or jurisdiction percentile, the greater consideration should be given to that target area. Target Average Case Mix Description Proportion of the sum of case mix weight for all episodes paid to the HHA during the report period, excluding LUPAs and PEPs, to the count of episodes paid to the HHA during the report period, excluding LUPAs and PEPs Target Home Health Agency Home Health Agency Home Health Agency Count/ Percent/ National Jurisdict. State Amount Rate %ile %ile %ile Sum of Payments Not Calculated Average Number of Episodes Episodes with 5 or 6 Visits Non-LUPA Payments Proportion of the count of episodes paid to the HHA during the report period, to the count of unique beneficiaries served by the HHA during the report period Proportion of the count of episodes with 5 or 6 visits paid to the HHA during the report period, to the count of episodes paid to the HHA during the report period Proportion of the count of episodes paid to the HHA that did not have a LUPA payment during the report period, to the count of episodes paid to the HHA during the report period $1,852, % $39, % $1,843,013 High Therapy Utilization Episodes Outlier Payments Proportion of the count of episodes with 20+ therapy visits paid to the HHA during the report period (first digit of HHRG equal to 5 ), to the count of episodes paid to the HHA during the report period Proportion of the dollar amount of outlier payments for episodes paid to the HHA during the report period, to the dollar amount of total payments for episodes paid to the HHA during the report period % $464,824 $8, % Not Calculated Note: State and/or jurisdiction %iles are not reported when there are fewer than 11 providers Worksheet: Compare with reportable data for the target area in the state and/or jurisdiction. File: Copy of _DMSTR_HHAPEPP_Q4CY15_Provider_D02271.xls

33 Home Health Agency PEPPER , Provider D02271 Need to audit? When reviewing this information, you may want to consider auditing a sample of records if you identify: Average Case Mix Visit PEPPERresources.org Link to Definitions Worksheet Increasing Target Rates over time resulting in greater risk of improper Medicare payments Your Target Rate (first row in the table below) is above the national 80th percentile Target Rate /1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Home Health Agency Natl: 80th %ile Juris: 80th %ile State: 80th %ile YOUR HOME HEATLH AGENCY 1/1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Target Area Rate Target Count: (Numerator: sum of case mix weight for all episodes paid to the HHA during the report period, excluding LUPAs (identified by Part A NCH HHA LUPA code) and PEPs (identified as patient discharge status code equal to 06 ) Denominator Count (Denominator: count of episodes paid to the HHA during the report period, excluding LUPAs and PEPs) Denominator Average Length of Stay *Data not available when numerator count less than 11 Note: State and/or jurisdiction percentiles are zero if there are fewer than 11 providers with reportable data for the target area in the state and/or jurisdiction. COMPARATIVE DATA National 80th Percentile Jurisdiction 80th Percentile State 80th Percentile Note: HHRG case mix weights changed (decreased) in CY 2014 from CY 2013 SUGGESTED INTERVENTIONS WHEN ABOVE 80th PERCENTILE: This could indicate a risk of potential overcoding of beneficiaries' clinical and functional status. The HHA should determine whether beneficiaries' clinical and functional status as reported on the OASIS is supported and consistent with medical record documentation. File: Copy of _DMSTR_HHAPEPP_Q4CY15_Provider_D02271.xls

34 Home Health Agency PEPPER , Provider D02271 Need to audit? When reviewing this information, you may want to consider auditing a sample of records if you identify: Average Number of Episodes Visit PEPPERresources.org Link to Definitions Worksheet Increasing Target Rates over time resulting in greater risk of improper Medicare payments Your Target Rate (first row in the table below) is above the national 80th percentile Target Rate /1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Home Health Agency Natl: 80th %ile Juris: 80th %ile State: 80th %ile YOUR HOME HEALTH AGENCY 1/1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Target Area Rate Target Count: (Numerator: count of episodes paid to the HHA during the report period Denominator Count (Denominator: count of unique beneficiaries served by the HHA during the report period Target (Numerator) Average Length of Stay Target (Numerator) Average Payment $2,767 $2,981 $3,314 Target (Numerator) Sum of Payments $1,217,382 $1,592,028 $1,852,613 *Data not available when numerator count less than 11 Note: State and/or jurisdiction percentiles are zero if there are fewer than 11 providers with reportable data for the target area in the state and/or jurisdiction. COMPARATIVE DATA National 80th Percentile Jurisdiction 80th Percentile State 80th Percentile SUGGESTED INTERVENTIONS WHEN ABOVE 80th PERCENTILE: This could indicate that the HHA is continuing treatment beyond the point where services are necessary. The HHA should review documentation for beneficiaries with a high number of episodes to ensure that it clearly substantiates that skilled services were reasonable and necessary to the treatment of the patient s illness or injury within the context of the patient s unique medical condition. If the individualized assessment of the patient does not demonstrate the need for skilled care, such as instances where skilled care could safely and effectively be performed by the patient or unskilled caregivers, such services are not covered under the home health benefit. The HHA should review plans of care for appropriateness and assess appropriateness of discharge plans. File: Copy of _DMSTR_HHAPEPP_Q4CY15_Provider_D02271.xls

35 Home Health Agency PEPPER , Provider D02271 Need to audit? When reviewing this information, you may want to consider auditing a sample of records if you identify: Increasing Target Percents over time resulting in greater risk of improper Medicare payments Your Target Percent (first row in the table below) is above the national 80th percentile Episodes with 5 or 6 Visits Target Percent 14% 12% 10% 8% 6% 4% 2% Visit PEPPERresources.org Link to Definitions Worksheet 0% 1/1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Home Health Agency Natl: 80th %ile Juris: 80th %ile State: 80th %ile YOUR HOME HEALTH AGENCY 1/1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Target Area Percent 5.2% 6.6% 4.1% Target Count: (Numerator: count of episodes with 5 or 6 visits paid to the HHA during the report period) Denominator Count (Denominator: count of episodes paid to the HHA during the report period) Target (Numerator) Average Length of Stay Denominator Average Length of Stay Target (Numerator) Average Payment $1,943 $1,680 $1,729 Target (Numerator) Sum of Payments $44,694 $58,804 $39,765 *Data not available when numerator count less than 11 Note: State and/or jurisdiction percentiles are zero if there are fewer than 11 providers with reportable data for the target area in the state and/or jurisdiction. COMPARATIVE DATA National 80th Percentile 11.8% 10.3% 10.1% Jurisdiction 80th Percentile 10.4% 9.6% 9.5% State 80th Percentile 11.9% 11.4% 10.9% SUGGESTED INTERVENTIONS WHEN ABOVE 80th PERCENTILE: This could indicate that the HHA is considering the minimum number of visits (5) to obtain an HHRG payment instead of a LUPA payment when there are less than 5 visits. The HHA should review documentation for episodes with 5 or 6 visits to ensure that it clearly substantiates that skilled services were reasonable and necessary to the treatment of the patient s illness or injury within the context of the patient s unique medical condition. If the individualized assessment of the patient does not demonstrate the need for skilled care, such as instances where skilled care could safely and effectively be performed by the patient or unskilled caregivers, such services are not covered under the home health benefit. The HHA should review plans of care to ensure they are individualized and appropriate for the beneficiaries condition. File: Copy of _DMSTR_HHAPEPP_Q4CY15_Provider_D02271.xls

36 Home Health Agency PEPPER , Provider D02271 Need to audit? When reviewing this information, you may want to consider auditing a sample of records if you identify: Non-LUPA Payments 120% 100% Visit PEPPERresources.org Link to Definitions Worksheet Increasing Target Percents over time resulting in greater risk of improper Medicare payments Your Target Percent (first row in the table below) is above the national 80th percentile Target Percent 80% 60% 40% 20% 0% 1/1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Home Health Agency Natl: 80th %ile Juris: 80th %ile State: 80th %ile YOUR HOME HEALTH AGENCY 1/1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Target Area Percent 90.2% 92.7% 95.2% Target Count: (Numerator: count of episodes paid to the HHA that did not have a LUPA payment during the report period) Denominator Count (Denominator: count of episodes paid to the HHA during the report period) Target (Numerator) Average Length of Stay Denominator Average Length of Stay Target (Numerator) Average Payment $3,030 $3,188 $3,464 Target (Numerator) Sum of Payments $1,202,935 $1,578,228 $1,843,013 *Data not available when numerator count less than 11 Note: State and/or jurisdiction percentiles are zero if there are fewer than 11 providers with reportable data for the target area in the state and/or jurisdiction. COMPARATIVE DATA National 80th Percentile 97.6% 97.6% 97.5% Jurisdiction 80th Percentile 95.6% 95.9% 95.2% State 80th Percentile 91.3% 92.7% 93.5% SUGGESTED INTERVENTIONS WHEN ABOVE 80th PERCENTILE: This could indicate that the HHA is considering the minimum number of visits (5) to obtain an HHRG payment instead of a LUPA payment where there are less than 5 visits. The HHA should review documentation to ensure that it clearly substantiates that skilled services were reasonable and necessary to the treatment of the patient s illness or injury within the context of the patient s unique medical condition. If the individualized assessment of the patient does not demonstrate the need for skilled care, such as instances where skilled care could safely and effectively be performed by the patient or unskilled caregivers, such services are not covered under the home health benefit. The HHA should review plans of care to ensure they are individualized and appropriate for the beneficiaries condition. File: Copy of _DMSTR_HHAPEPP_Q4CY15_Provider_D02271.xls

37 Home Health Agency PEPPER , Provider D02271 Need to audit? When reviewing this information, you may want to consider auditing a sample of records if you identify: Increasing Target Percents over time resulting in greater risk of improper Medicare payments Your Target Percent (first row in the table below) is above the national 80th percentile High Therapy Utilization Episodes Target Percent 16% 14% 12% 10% 8% 6% 4% 2% Visit PEPPERresources.org Link to Definitions Worksheet 0% 1/1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Home Health Agency Natl: 80th %ile Juris: 80th %ile State: 80th %ile YOUR HOME HEALTH AGENCY 1/1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Target Area Percent 3.4% 12.4% 14.7% Target Count: (Numerator: count of episodes with 20+ therapy visits paid to the HHA during the report period (first digit of HHRG equal to '5') Denominator Count (Denominator: count of episodes paid to the HHA during the report period) Target (Numerator) Average Length of Stay Denominator Average Length of Stay Target (Numerator) Average Payment $5,757 $5,488 $5,669 Target (Numerator) Sum of Payments $86,349 $362,228 $464,824 *Data not available when numerator count less than 11 Note: State and/or jurisdiction percentiles are zero if there are fewer than 11 providers with reportable data for the target area in the state and/or jurisdiction. COMPARATIVE DATA National 80th Percentile 12.3% 12.7% 14.2% Jurisdiction 80th Percentile 8.7% 9.5% 11.1% State 80th Percentile 7.5% 13.2% 12.3% SUGGESTED INTERVENTIONS WHEN ABOVE 80th PERCENTILE: This could indicate that the HHA is improperly billing for therapy services. The HHA should review documentation for episodes with 20+ therapy visits to ensure that it clearly substantiates that skilled therapy services were reasonable and necessary. This includes ensuring that the specialized judgement, knowledge and skills of a qualified therapist ( skilled care ) were necessary to prevent deterioration and/or to preserve the beneficiary s existing capabilities. The HHA should ensure that the amount of therapy reported is supported by documentation in the medical record. File: Copy of _DMSTR_HHAPEPP_Q4CY15_Provider_D02271.xls

38 Home Health Agency PEPPER , Provider D02271 Need to audit? When reviewing this information, you may want to consider auditing a sample of records if you identify: Increasing Target Percents over time resulting in greater risk of improper Medicare payments Your Target Percent (first row in the table below) is above the national 80th percentile Outlier Payments Target Percent 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% Visit PEPPERresources.org Link to Definitions Worksheet 0% 1/1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Home Health Agency Natl: 80th %ile Juris: 80th %ile State: 80th %ile YOUR HOME HEALTH AGENCY 1/1/13 12/31/13 1/1/14 12/31/14 1/1/15 12/31/15 Target Area Percent * 0.2% 0.4% Target Count: (Numerator: sum of dollar amount of outlier payments (identified by the amount where Value Code equal to 17 ) for episodes paid to the HHA during the report period) $3,408 $8,011 Denominator Count (Denominator: sum of dollar amount of total payments for episodes paid to the HHA during the report period) $1,592,028 $1,852,613 Target (Numerator) Average Length of Stay Denominator Average Length of Stay *Data not available when numerator count less than 11 Note: State and/or jurisdiction percentiles are zero if there are fewer than 11 providers with reportable data for the target area in the state and/or jurisdiction. COMPARATIVE DATA National 80th Percentile 9.1% 9.0% 7.6% Jurisdiction 80th Percentile 8.4% 7.7% 6.1% State 80th Percentile 0.0% 0.0% 0.0% SUGGESTED INTERVENTIONS WHEN ABOVE 80th PERCENTILE: This could indicate that the HHA is providing costly services to beneficiaries when they are not medically necessary. Claims with outlier payments should be reviewed to ensure treatment provided was medically necessary. File: Copy of _DMSTR_HHAPEPP_Q4CY15_Provider_D02271.xls

39 Home Health Agency PEPPER Top Diagnoses Provider D02271 Visit PEPPERresources.org Home Health Agency Top Diagnoses, Most Recent Calendar Year In Descending Order by Total Episodes CCS Diagnosis Categories Rehabilitation care; fitting of prostheses; and adjustment of device Other aftercare Congestive heart failure; nonhypertensive Chronic obstructive pulmonary disease and bronchiectasis Diabetes mellitus with complications Late effects of cerebrovascular disease Complications of surgical procedures or medical care Pneumonia (except that caused by tuberculosis or sexually transm Other nervous system disorders Other fractures Chronic ulcer of skin Diabetes mellitus without complication Delirium, dementia, and amnestic and other cognitive disorders Fracture of upper limb Acute myocardial infarction Cardiac dysrhythmias Total Episodes for CCS Category Proportion of Episodes for CCS to Total Episodes Number of Visits for CCS Category Average Number of Visits for CCS Category % % 1, % % % % % % % % % % % % % % Top Diagnoses % 7, All Diagnoses , Note: This report is limited to the top diagnosis categories (up to 20) for which there are a total of at least 11 episodes ending in the most recent calendar year. The principal diagnosis code for episodes ending in the most recent calendar year have been collapsed into general categories using Clinical Classification Software (CCS). More information on CCS can be found at

40 Home Health Agency PEPPER Home Health Agencies for Demo Jurisdiction (DMSTR) Visit PEPPERresources.org Jurisdiction Top Diagnoses, Most Recent Calendar Year In Descending Order by Total Episodes Total Episodes for CCS Category Proportion of Episodes for CCS to Total Episodes Number of Visits for CCS Category Average Number of Visits for CCS Category CCS Diagnosis Categories Other aftercare 47, % 753, Congestive heart failure; nonhypertensive 21, % 396, Rehabilitation care; fitting of prostheses; and adjustment of device 21, % 286, Chronic obstructive pulmonary disease and bronchiectasis 14, % 246, Chronic ulcer of skin 11, % 280, Other nervous system disorders 9, % 181, Other fractures 7, % 153, Diabetes mellitus with complications 7, % 173, Cardiac dysrhythmias 7, % 124, Genitourinary symptoms and ill-defined conditions 6, % 108, Late effects of cerebrovascular disease 6, % 166, Other connective tissue disease 6, % 131, Pneumonia (except that caused by tuberculosis or sexually transm 6, % 102, Open wounds of extremities 5, % 115, Essential hypertension 5, % 95, Complications of surgical procedures or medical care 5, % 117, Urinary tract infections 5, % 93, Skin and subcutaneous tissue infections 5, % 98, Other diseases of veins and lymphatics 5, % 114, Diabetes mellitus without complication 5, % 132, Top Diagnoses Jurisdiction-wide 212, % 3,871, All Diagnoses Jurisdiction-wide 319,605 5,833, Note: This report is limited to the top diagnosis categories (up to 20) for which there are a total of at least 11 episodes ending in the most recent calendar year. The principal diagnosis code for episodes ending in the most recent calendar year have been collapsed into general categories using Clinical Classification Software (CCS). More information on CCS can be found at

41 Home Health Agency PEPPER Top Therapy Report , Provider D02271 Visit PEPPERresources.org Home Health Agency Top Therapy Episodes, Most Recent Calendar Year In Descending Order by Total Episodes CCS Diagnosis Categories Early Episodes, 0-13 Therapy Visits Other aftercare Rehabilitation care; fitting of prostheses; and adjustment of devices Congestive heart failure; nonhypertensive Complications of surgical procedures or medical care Chronic obstructive pulmonary disease and bronchiectasis Early Episodes, Therapy Visits Rehabilitation care; fitting of prostheses; and adjustment of devices Number of Proportion of Episodes all Episodes Proportion Within Episode Group Number of Therapy Visits Average Number of Therapy Visits % 1, % % % % % % 1, % Late Episodes, 0-13 Therapy Visits Diabetes mellitus with complications Congestive heart failure; nonhypertensive % % % Late Episodes, Therapy Visits % Early or Late Episodes, 20+ Therapy Visits % 2, Total % 5, Note: Episodes ending in the most recent calendar year are considered for this report and are categorized into a therapy episode group based on the first digit in the HIPPS code as reported on the claim. Data for a therapy episode group will not be displayed if there are fewer than 11 episodes for the respective therapy episode group. This report is limited to the top diagnosis categories (up to 5) for which there are a total of at least 11 episodes for a diagnosis category within the respective therapy episode group. The principal diagnosis code for episodes have been collapsed into general categories using Clinical Classification Software (CCS). More information on CCS can be found at

42 Home Health Agency PEPPER Home Health Agencies for Demo Jurisdiction (DMSTR) Visit PEPPERresources.org Jurisdiction Top Therapy Episodes, Most Recent Calendar Year In Descending Order by Total Episodes CCS Diagnosis Categories Early Episodes, 0-13 Therapy Visits Other aftercare Rehabilitation care; fitting of prostheses; and adjustment of devices Congestive heart failure; nonhypertensive Chronic obstructive pulmonary disease and bronchiectasis Other nervous system disorders Early Episodes, Therapy Visits Other aftercare Rehabilitation care; fitting of prostheses; and adjustment of devices Other nervous system disorders Congestive heart failure; nonhypertensive Other fractures Late Episodes, 0-13 Therapy Visits Congestive heart failure; nonhypertensive Chronic ulcer of skin Genitourinary symptoms and ill-defined conditions Deficiency and other anemia Chronic obstructive pulmonary disease and bronchiectasis Late Episodes, Therapy Visits Rehabilitation care; fitting of prostheses; and adjustment of devices Congestive heart failure; nonhypertensive Other aftercare Other nervous system disorders Chronic ulcer of skin Early or Late Episodes, 20+ Therapy Visits Other aftercare Rehabilitation care; fitting of prostheses; and adjustment of devices Late effects of cerebrovascular disease Other nervous system disorders Congestive heart failure; nonhypertensive Total Number of Episodes Proportion of all Episodes Proportion Within Episode Group Number of Therapy Visits Average Number of Therapy Visits 202, % 900, , % 190, , % 115, , % 49, , % 35, , % 37, , % 418, , % 67, , % 53, , % 22, , % 20, , % 18, , % 159, , % 15, , % 7, , % 4, , % 3, , % 7, , % 85, % 10, % 6, % 4, % 4, % 3, , % 479, , % 51, , % 46, , % 44, , % 27, % 21, , % 2,042, Note: Episodes ending in the most recent calendar year are considered for this report and are categorized into a therapy episode group based on the first digit in the HIPPS code as reported on the claim. Data for a therapy episode group will not be displayed if there are fewer than 11 episodes for the respective therapy episode group. This report is limited to the top diagnosis categories (up to 5) for which there are a total of at least 11 episodes for a diagnosis category within the respective therapy episode group. The principal diagnosis code for episodes have been collapsed into general categories using Clinical Classification Software (CCS). More information on CCS can be found at