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About the presenter ARLENE MAXIM, RN President & Founder A.D. Maxim Consulting, LLC
Quality health care for people with Medicare is a high priority for the Department of Health and Human Services, and the Centers for Medicare & Medicaid Services (CMS).
Institute of Medicine Mission CMS has adopted the mission of The Institute of Medicine (IOM). The IOM has which has defined quality as having specific properties.
Institute of Medicine Mission Effectiveness Relates to providing care processes and achieving outcomes as supported by scientific evidence. Efficiency Relates to maximizing the quality of a comparable unit of health care delivered or unit of health benefit achieved for a given unit of health care resources used.
Institute of Medicine Mission Equity Relates to providing health care of equal quality to those who may differ in personal characteristics other than their clinical condition or preferences for care. Patient Centeredness Relates to meeting patients needs and preferences and providing education and support. Safety Relates to actual or potential bodily harm. Timeliness Relates to obtaining needed care while minimizing delays.
What We Should Expect Increased Reviews Some based on increased reporting: Pepper Reports Star Reports Casper Reports
What is PEPPER? Pepper Report
What is PEPPER?
What is PEPPER? Program for Evaluating Payment Patterns Electronic Report
What is PEPPER? PEPPER is a Microsoft Excel file that summarizes homecare-specific Medicare data statistics for target areas. They are looking for improper payments due to billing and coding. UB-04 claims are used for analysis to determine whether or not the admission was even necessary. Target areas for each provider type are determined by CMS. NOTE: Coding is one of those Target Areas The results of the PEPPER report should help the Agency to prioritize areas to focus auditing and review of claims.
What is PEPPER? The report will provide three years of data statistics for each of the CMS target areas. The report will compare YOUR performance to that of other Agencies In the nation Specific Medicare Administrative Contractor (MAC) jurisdiction State This report will also allow Medicare (and the Agency) an opportunity to compare data statistics over time.
What is PEPPER? The Agency will be able to identify and isolate: Any changes in billing practices Any areas needing special auditing and monitoring Potential HRRG s issues Under-or-over-coding problems An increase in length of stay
What is PEPPER? 2011 PEPPER was developed for critical access hospitals, inpatient psychiatric facilities and inpatient rehabilitation facilities. 2012 PEPPER was developed for hospices and partial hospitalization programs. 2013 PEPPER was developed for skilled nursing facilities. 2015 PEPPER developed for home health agencies released in July
Why PEPPER?
PREDICTIONS ARE CRITICAL to your success: To make accurate predictions, you will need to be able to analyze the current information included in the report as it relates to YOUR agency.
1. How is an outlier defined for purposes of this analysis? For home health purposes, most people think of an outlier as the number of patients that get daily insulin injections. This isn t what it means here!!!!! One of the targeted areas is specific to the number of outliers. For instance: Higher number than usual of LUPA or Near LUPA claims (5-6 visits) Up coding of Clinical and Functional Status. Assuring that OASIS items chosen are supported and consistent with documentation in the medical record. RECOMMEND: a process in place to predict risk.
2. Where can I find more information about PEPPER? PEPPERresources.org 3. How far back will the analysis go? 3 consecutive years
4. How can I predict my risk? Watch for targeted areas!!!! THEY ARE NOT: geographic areas!!!! THEY ARE: Claims related areas 1. Average Case Mix 2. Average Number of Episodes 3. Episodes with 5 or 6 visits 4. Non-Lupa Payments 5. High Therapy Utilization 6. Outlier Payments
5. RISK and Recommendations Areas of Risk:! Average Case Mix Potential over coding of clinical and functional status. RECOMMEND: Be very sure there is clear and concise documentation in the clinical record to support OASIS clinical and functional scores applied.! Average Number of Episodes (Recertifications) Looking for keeping patients beyond the point when services are really necessary. RECOMMEND: Be sure there is clear supportive documentation in the record to support why the services are reasonable and necessary to the illness/ injury related to the UNIQUE medical condition.
5. RISK and Recommendations Areas of Risk:! Episodes with 5-6 visits Looks as though adding visits to obtain a HRRG payment instead of LUPA RECOMMEND: a. Documentation must be reviewed and analyzed. b. Carefully review the Plan of Care to ensure it is INDIVIDUALIZED and appropriate to the patients condition. c. Watch for evidence that could indicate care could have been provided by a non-skilled caregiver.
5. RISK and Recommendations Areas of Risk:! Non-LUPA Payments When there are minimum number of visits (5) completed, it could be looked at as yet another effort to get a HRRG payment as opposed to a LUPA payment. RECOMMEND: Be very sure that all assessments (by ALL disciplines) are consistent and demonstrate a UNIQUE need for the patient. Carefully review the plans of care to ensure plans are INDIVIDUALIZED and APPROPRIATE for the patients UNIQUE condition.
5. RISK and Recommendations Areas of Risk:! High Therapy Utilization Of therapy utilization is too high, there could be indication the agency is improperly billing for therapy services. RECOMMEND: Review all documentation with episodes having >20 therapy visits. 1. Clear indication that services are reasonable and necessary for the patients UNIQUE condition. 2. That care provided required the skills of the therapist to restore or maintain deterioration of condition. 3. That the documentation supports all of the above
5. RISK and Recommendations Areas of Risk:! Outlier Payments Looking for indication of overcoding OR undercoding the patients condition clinically and functionally. RECOMMEND: Review record carefully to be certain the clinical and functional status reported in OASIS is fully supported by clear and consistent assessment information.
More Recommendations
! Billing for Assessment Visit ONLY by the RN!!! Areas of Risk: Many agencies right now who are billing for RN SOC s for one visit when it is a therapy only case. These patients have no skill provided and no order for intermittent ongoing skilled care for the nurse. When this turns into a 5 visit full pay episode they are at a great risk for overpayment determination on medical review. The Medicare payment system will automatically pay episodes with single RN visits and four therapy visits because it can t know if the single nursing visit was validly billed as a skilled visit.
! Inappropriate Goals and Interventions Areas of Risk: Interventions NOT appropriate for the patient and their conditions-incorrect G CODES!!! GOALS NOT MEASURABLE PROGRESS TOWARD GOALS NOT IDENTIFIED
! Incorrect Q Codes Areas of Risk: Assisted Living Facilities (ALF s)
Who benefits from PEPPER?
Who benefits from PEPPER? CEO S AND ADMINISTRATORS Access tables and graphs displaying billing activity over time in comparison with other agencies Review agency data and comparative target area statistics for the state, jurisdiction, and nation Track and trend administrative data statistics to identify changes in billing practices and Medicare reimbursement for CMS target areas
Who benefits from PEPPER? CHIEF FINANCIAL OFFICERS Identify areas of potential overpayments and underpayments Identify HRRG s with a high proportion of LUPA s and outliers Compare re-certification data to other Agencies in State/Region/Community served Assess Medicare reimbursement for target areas, track and trend over time
Who benefits from PEPPER? COMPLIANCE OFFICERS Review agency data for target areas identified by CMS as a high risk for improper payment Help prioritize areas for compliance auditing and monitoring Access data tables and graphs displaying billing activity over time in comparison with other agencies
Who benefits from PEPPER? QUALITY IMPROVEMENT STAFF Identify areas that may be in need of a closer look to determine if patient met all eligibility criteriaincluding homebound status and Face-to-Face requirements Assess hospital readmission rates to assist in identifying opportunities for improvement related to case management, discharge planning and quality of care Identify target areas where the average length of stay is increasing (or decreasing) Aid efforts to improve medical record documentation
Star Ratings Two types of star ratings 1. Patient Survey Star Ratings available January 2016 2. Quality of Patient Care Star Ratings (used to be called HHC Star Ratings)
NEW! Patient Survey Star Ratings NEW IN 2016! Many stakeholders have proposed that the patient experience of care measures, based on the HHCAHPS survey data, be reflected in the star ratings.
NEW! Patient Survey Star Ratings NEW Coming your way on January 28, 2016! CMS has been developing: Ratings will be provided for four measures included in Home Health Compare 1. Communication between Providers and Patients 2. Specific Care Issues 3. Overall Rating of Care Provided by the Agency 4. Summary Star-this is based on the four HHCAHPS measures receiving Star Ratings-they are averaged and then rounded up
HHCAHPS Measures for Star Ratings Four HHCAHPS measures will receive a Star Rating: Composite Measures 1. Care of Patients 2. Communication Between Providers and Patients 3. Specific Care Issues Global Item 4. Overall Rating of Care Provided by the HHA There will also be a Survey Summary Star Rating
PREVIEW REPORT for Patient Survey Star Ratings The report WILL NOT be issued publicly. CMS wants to give the agency a chance to see how they compare with other agencies ratings. The first ratings to go public will occur in January of 2016, reflecting data for patients services from July 2014 through June 2015.
Quality of Patient Care Star Ratings Quality of Patient Care Star Rating (formerly HHC, Star Rating) - 2015 This new name was established so that there would be clear definition between the two individual Star ratings. This rating is 100% based on OASIS assessments and claims data presented by the Agency.
Quality of Patient Care Star Ratings Measures included: The Quality of Patient Care Star Rating is determined by nine of the twenty-seven Process and Outcome quality measures that are currently reported.
Quality of Patient Care Star Ratings The 9 measures are: Process Measures: 1. Timely Initiation of Care 2. Drug Education on all Medications Provided to Patient/Caregiver 3. Influenza Immunization Received for Current Flu Season Outcome Measures: 4. Improvement in Ambulation 5. Improvement in Bed Transferring 6. Improvement in Bathing 7. Improvement in Pain Interfering with Activity 8. Improvement in Shortness of Breath 9. Acute Care Hospitalization
Which HHAs receive Star Ratings? ALL Medicare-certified HHAs are potentially eligible to receive a star rating. Currently, HHAs must have at least 20 complete quality episodes for data for each measure to be reported on HHC. (SOC/Resumption and end of care OASIS assessments) Episodes must have discharge date within the 12- month reporting period regardless of admission date. HHAs must have reported data for 5 of the 9 measures used in the Quality of Patient Care Star Ratings calculation.
When will Quality of Patient Care Star Ratings be published? Quality of Patient Care Star Ratings were published on HHC beginning in mid-july 2015 and quarterly thereafter. The Quality of Patient Care Star Ratings will be updated each quarter based on the new data that are published on Home Health Compare.
Why use Star Ratings? Star Ratings are a summary of agency performance and quality of care in a form the general public can understand (much like hotels and restaurants star ratings). These ratings identify the difference in healthcare quality and identify areas in care that need improvement. Ratings are thought to be a useful tool for consumers, healthcare providers, and all stakeholders. Ratings are updated with the most current information available.
Why use Star Ratings? (continued) The Affordable Care Act (ACA) indicated information must be transparent and easily understood by the general public. Of course, star ratings are something very familiar to everyone.
Star Ratings Impact A recent article in home health line indicated agencies in Washington and Oregon received a letter from a Medicare Advantage Program indicating STAR ratings below 5 would cost them. For example: A 2- to 3-star = 75% of the standard episode rate A 4-star = 85% The problem: 9,000 agencies were rated by CMS 2.6% earned 5 stars 8.3% earned 4.5 stars. In this case, agencies with higher STAR ratings will receive 100% of the rate.
Star Ratings Impact! Pennsylvania Agency with 3.5 STARS had contract terminated.! In a recent Amedisys article, the CEO indicated that STAR ratings influenced his decision on which agency to purchase.
3 Steps to YOUR STARS!!!!!! 1. Use CASPER login and password 2. Login to CASPER - click on the Folders link a. My Inbox Click on HHA. (DO NOT CLICK ON VALIDATION REPORT) b. Click on the link for the facility ID (in the left column My Inbox ) 3. Right Click on the HHC Star Rating Preview Home Health Start Rating Provider Preview Report appears!!!
Star Ratings The Star Ratings are available for ALL healthcare providers with Medicare Compare websites. It is said to be another way for the general public to measure quality of care, provide consumer choice and to encourage homecare agencies to do a better job.
Performing internal audits and avoiding denials BILLING for PAYMENT in the POST-ICD-10 WORLD
Quiz Staff Regularly Assess employee comprehension of their duties through quizzes tailored to their duties and responsibilities Coders Coding Principles and Conventions Clinicians OASIS C1, Comprehensive Assessments Billers Q Codes, G-Codes, recognizing ICD-10 errors
The Most Common Reasons for Denials/Rejections
1. No Physician Certification This could mean that the Face-to- Face included did not meet the guidelines, or perhaps the certification statement was not signed and dated by the physician.
2. Documentation provided did not support homebound status The documentation must demonstrate that leaving the home requires taxing effort and therefore the patient does not leave the home often.
3. Physician orders were not signed in a timely fashion The Plan of Care and all verbal orders must be signed and dated prior to submission of the home health claim.
4. Watch the HETS system (HIPAA Eligibility Transaction System) Watch out for: Open episodes of other agencies Termination of the patient s Medicare benefits before admission Existing Medicare Advantage Plans If your practice management software does not automatically detect these eligibility conflicts for you, you must ensure that the staff members responsible are meticulous and attentive.
5. Duplicate Billing/ Duplicated RAPs Always double-check your claims records and RAs before submitting new claims Do not submit the final claim for an episode until its submitted RAP has been completely processed If a final claim needs to be corrected, do not resubmit the RAP just the adjusted final claim
RESOURCES PEPPER Reports www.pepperresources.org CMS Star Rating www.cms.gov/medicare/quality-initiatives-patient-assessment Instruments/HomeHealthQualitylnits/HHQIHomeHealth StarRatings.html www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html Home Health Compare www.medicare.gov/homehealthcompare
Thank you! ARLENE MAXIM, RN President & Founder A.D. Maxim Consulting, LLC More information about A.D. Maxim Consulting: 248-457-9227 info@admaximconsulting.com www.admaximconsulting.com 900 Wilshire Ste. 351 Troy, MI 48084
This educational presentation is provided by The software that powers post-acute care. HOME HEALTH. HOSPICE. THERAPY. PRIVATE DUTY 877.399.6538 info@kinnser.com www.kinnser.com
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APPENDIX
Home Health Agency Program for Evaluating Payment Patterns Electronic Report User s Guide First Edition Prepared by
Home Health Agency Program for Evaluating Payment Patterns Electronic Report User s Guide First Edition, effective with the Q4CY14 release Prepared by TMF Health Quality Institute Introduction... 3 What Is PEPPER?... 3 HHA PEPPER CMS Target Areas... 5 How HHAs Can Use PEPPER Data... 6 Using PEPPER... 8 Compare Targets Report... 8 Target Area Reports... 9 HHA Top Diagnoses Report... 10 HHA Top Therapy Episodes Report... 11 Jurisdiction-wide Top Diagnoses Report... 11 Jurisdiction-wide Top Therapy Episodes Report... 11 System Requirements, Customer Support and Technical Assistance... 11 Glossary... 13 Acronyms and Abbreviations... 14 HHA PEPPER User s Guide, First Edition 2
Introduction The Government Accountability Office has designated Medicare as a program at high risk for fraud, waste and abuse 1. Medicare spending for home health care has increased dramatically in recent years 2, 3 and home health agencies (HHAs) have been designated as providing Medicare services that have a high risk for fraud, waste and abuse 4.The OIG recommended that the Centers for Medicare & Medicaid Services (CMS) increase monitoring of billing for home health services 4. In 1999 the Office of Inspector General (OIG) encouraged health care providers to develop and implement a compliance program to protect their operations from fraud and abuse. 5 As part of a compliance program, HHAs should conduct regular audits to ensure charges for Medicare services are correctly documented and billed. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide a provider s auditing and monitoring activities with the goal of preventing improper Medicare payments. What Is PEPPER? The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a comparative data report that summarizes a single provider s Medicare claims data statistics in areas identified as at risk for improper Medicare payments. To develop the HHA PEPPER, Medicare claims data for all HHAs in the nation (obtained from the UB-04 claims submitted to the Medicare Administrative Contractor or MAC) were analyzed to identify areas which could be at risk for improper Medicare payment. These areas are referred to as target areas. PEPPER does not identify the presence of improper payments, but it can be used as a guide for auditing and monitoring efforts. A HHA can use PEPPER to compare its claims data over time to identify areas of potential concern and to identify changes in billing practices. Each HHA with sufficient data to generate a report receives a PEPPER, which summarizes statistics for these target areas regardless of whether the HHA s data are of concern. The report shows how an agency s data compares to national, jurisdiction and state statistics. Data in PEPPER are presented in tabular form as well as in graphs that depict the HHA s target area percentages/rates over time. All of the data tables, graphs and reports in PEPPER were designed to assist the HHA in identifying potentially improper payments. PEPPER is developed and distributed by TMF Health Quality Institute, under contract with the Centers for Medicare & Medicaid Services (CMS). 1 Government Accountability Office. Medicare Fraud, Waste and Abuse: Challenges and Strategies for Preventing Improper Payments. June 15, 2012. Available at: http://www.gao.gov/new.items/d10844t.pdf. 2 Medicare Payment Advisory Commission. Medicare Payment Policy Report to Congress, March 2015, chapter 9, available at http://www.medpac.gov/documents/reports/march-2015-report-to-the-congress-medicare-paymentpolicy.pdf?sfvrsn=0 3 Medicare and Medicaid Research Review 2013 Statistical Supplement, available at http://www.cms.gov/research- Statistics-Data-and-Systems/Statistics-Trends-and- Reports/MedicareMedicaidStatSupp/Downloads/2013_Section7.pdf#Table7.1 4 Office of Inspector General. Inappropriate and Questionable Billing by Medicare Home Health Agencies. 2012. Available at http://oig.hhs.gov/oei/reports/oei-04-11-00240.asp 5 Department of Health and Human Services/Office of Inspector General. 1998. Publication of the OIG Compliance Program, Guidance for Home Health Agencies, Federal Register 63, no. 152, August 7, 1998, 42410 42426. Available at: http://oig.hhs.gov/authorities/docs/cpghome.pdf HHA PEPPER User s Guide, First Edition 3
Beginning in 2015 PEPPER is available for HHAs. PEPPER is also available for short- and long-term acute care inpatient Prospective Payment System (PPS) hospitals, critical access hospitals, inpatient psychiatric facilities, inpatient rehabilitation facilities, partial hospitalization programs, hospices, and skilled nursing facilities (the format of the reports and the target areas are customized for each setting). The HHA PEPPER is the version of PEPPER specifically developed for HHAs. Beginning with the Q4CY14 release (July 2015), the HHA PEPPER will be available to the HHA s Chief Executive Officer, Administrator or President through the PEPPER Resources Portal (accessible through http://pepperresources.org/). Each HHA receives only its PEPPER; PEPPER is not available for public release. TMF does not provide PEPPERs to other contractors, although TMF does provide an Access database (the First-look Analysis Tool for Hospital Outlier Monitoring, or FATHOM) to MACs and Recovery Auditors. FATHOM can be used to produce a PEPPER. Each HHA PEPPER summarizes claims data statistics (obtained from paid home health Medicare UB-04 claims) for the most recent three calendar years (the calendar year begins January 1 and ends December 31). A HHA is compared to other HHAs in three comparison groups: nation, MAC jurisdiction and state. These comparisons enable an HHA to determine if its billing statistics differ from other HHAs and if it may be at higher risk for improper Medicare payments. PEPPER identifies areas at risk for improper Medicare payments based on preset control limits. The upper control limit for all target areas is the national 80 th percentile. Coding-focused target areas also have a lower control limit, which is the national 20 th percentile. Currently the HHA PEPPER does not contain any coding-focused target areas; therefore, the HHA PEPPER draws attention to any findings that are at or above the national 80 th percentile. In order to be eligible for inclusion in the HHA PEPPER claims must meet the specifications shown below. INCLUSION/EXCLUSION CRITERIA Claim facility type equal to 3 Include claim service classification type of Home health visits Exclude non-payment and interim claims Final action claim Medicare claim payment amount greater than zero Exclude Health Maintenance Organization claims Exclude cancelled claims DATA SPECIFICATIONS UB-04 Form Locator (FL) 04 Type of Bill, second digit (Type of Facility) = 3 (Home health agency) UB-04 FL 04 Type of Bill, third digit (Bill Classification) = 2 (Home health visits under Part B) or 3 (Home health visits Part A) UB-04 FL 04 Type of Bill, fourth digit (Frequency) 0 (Nonpayment/zero claim) or 2 (Interim first claim) A final action claim is a non-rejected claim for which a payment has been made. All disputes and adjustments have been resolved and details clarified. The home health agency received a payment amount greater than zero on the claim (Note that Medicare Secondary Payer claims are included). Exclude claims submitted to a Medicare Advantage (Health Maintenance Organization) plan Exclude claims cancelled by the Medicare Administrative Contractor HHA PEPPER User s Guide, First Edition 4
Medicare home health care consists of skilled nursing, physical therapy, occupational therapy, speech therapy, aide services and medical social work provided to beneficiaries in their homes. CMS uses a prospective payment system (PPS) that establishes a predetermined reimbursement rate for each 60-day episode of home health care. To capture differences in expected resource use, patients receiving five or more visits are assigned to one of 153 home health resource groups (HHRGs) based on clinical and functional status and service use as measured by the Outcome and Assessment Information Set (OASIS). The 153 HHRGs are divided into five categories based on the amount of therapy provided and the episode s timing in a sequence of episodes. Medicare makes additional payments, known as outlier payments, to HHAs that provide services to beneficiaries who incur unusually high costs. If fewer than five visits are delivered during a 60-day episode, the low-utilization payment adjustment (LUPA) rate is applied and the HHA is paid per visit by visit type. The HHA PPS includes a partial episode payment (PEP) adjustment when a beneficiary elects to transfer to another HHA or when a beneficiary is discharged and readmitted to the same HHA during the 60-day episode. A beneficiary can receive an unlimited number of episodes as long as they meet coverage criteria. For home health services, an episode is represented by one claim submitted to the MAC for Medicare reimbursement. The PEPPER target areas were designed to report on beneficiary episodes (claims) that end during the respective calendar year. HHA PEPPER CMS Target Areas In general, the target areas are constructed as ratios and expressed as percents or rates, with the numerator representing episodes that may be identified as problematic in terms of risk for improper Medicare payment, and the denominator representing a larger comparison group. The HHA PEPPER target areas are defined in the table below. TARGET AREA Average Case Mix (Avg Case Mix) 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 Average Number of Episodes (Nbr Episodes) Episodes with 5 or 6 Visits (5 or 6 visits) Non-LUPA Payments (NonLUPA) Note: reported as a rate, not a percent. 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 Note: reported as a rate, not a percent. 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 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 HHA PEPPER User s Guide, First Edition 5
High Therapy Utilization Episodes (Hi Therapy Utiliz) Outlier Payments (Outlier) 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 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 These PEPPER target areas were approved by CMS because they have been identified as being potentially at risk for improper Medicare payments in the HHA PPS. How HHAs Can Use PEPPER Data The HHA PEPPER allows HHAs to compare their billing statistics with national, jurisdiction and state percentile values for each target area for which they have reportable data for the most recent three years. Reportable data in PEPPER means the numerator count is 11 or more for a given target area for a given time period. When the numerator count is less than 11 for a target area for a time period, statistics are not displayed in PEPPER due to CMS data restrictions. To calculate percentiles, the target area percents/rates for all HHAs with reportable data for each target area and each time period in the respective comparison group (nation, jurisdiction or state) are ordered from highest to lowest. The target area percent/rate below which 80 percent of all HHAs target area percents/rates falls is identified as the 80 th percentile. HHAs whose target percents/rates are at or above the 80 th percentile (i.e., the top 20 percent) are considered at risk for improper Medicare payments. Percentiles are calculated for each of the three comparison groups (nation, jurisdiction and state). The greater the HHA s percentile, the greater risk for improper payments. TMF has developed suggested interventions that HHAs could consider when assessing their risk for improper Medicare payments for each of the target areas. Please note that these are generalized suggestions and will not apply to all situations. The following table can assist HHAs with interpreting their percentile values which are indications of possible risk of improper Medicare payments. TARGET AREA Average Case Mix (Case Mix) Average Number of Episodes (Nbr Episodes) SUGGESTED INTERVENTIONS FOR HHAs AT RISK FOR IMPROPER PAYMENTS (IF AT/ABOVE 80 TH 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. 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 HHA PEPPER User s Guide, First Edition 6
Episodes with 5 or 6 Visits (5 or 6 visits) Non-LUPA Payments (NonLUPA) High Therapy Utilization Episodes (Hi Therapy Utiliz) Outlier Payments (Outlier) 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. 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. 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. 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. 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. Comparative data for the three consecutive years can be used to help identify whether the HHA s target area percents/rates changed significantly in either direction from one year to the next. This could be an indication of a changes in admission or treatment practices, staff turnover, a change in medical staff, or changes in the external healthcare environment. HHA PEPPER User s Guide, First Edition 7
Using PEPPER Compare Targets Report HHAs can use the Compare Targets Report to help prioritize areas for auditing and monitoring. The Compare Targets Report lists all target areas with reportable data for the most recent year included in PEPPER. For each target area, the Compare Targets Report displays the HHA s numerator count; percent/rate; HHA s percentiles as compared to the nation, jurisdiction and state; and the Sum of Payments (where applicable). Navigate through PEPPER by clicking on the worksheet tabs at the bottom of the screen. Each tab is labeled to identify the contents of each worksheet (e.g., Target Area Reports, Compare Targets Report). The HHA PEPPER identifies providers whose data results (percentiles) suggest they are at risk for improper Medicare payments as compared to all HHAs in the nation. The HHA s risk status is indicated by the color of the target area percent/rate on the Compare Targets Report. When the HHA s percent/rate is at or above the national 80 th percentile for a target area, the HHA s percent/rate is printed in red bold. When the HHA s percent/rate is below the national 80 th percentile, the HHA s percent/rate is printed in black. The Compare Targets Report provides the HHA s percentile value for the nation, jurisdiction and state for all target areas with reportable data in the most recent year. The percentile value allows a HHA to judge how its target area percent/rate compares to all HHAs in each respective comparison group. (See Percentile in the Glossary, page 13.) The HHA s national percentile indicates the percentage of all other HHAs in the nation that have a target area percent/rate less than the HHA s target area percent/rate. The HHA s jurisdiction percentile indicates the percentage of all other HHAs in the MAC jurisdiction that have a target area percent/rate less than the HHA s target area percent/rate. The HHA s jurisdiction percentile for a target area will be blank if there are fewer than 11 HHAs with reportable data for the target area in a jurisdiction. The HHA s state percentile indicates the percentage of all other HHAs in the state that have a target area percent/rate less than the HHA s target area percent/rate. The HHA s state percentile for a target area will be blank if there are fewer than 11 HHAs with reportable data for the target area in a state For more on percents versus percentiles, see the Training and Resources page in the HHA section on PEPPERresources.org for a short slide presentation with visuals to assist in the understanding of these terms. When interpreting the Compare Targets Report findings, HHAs should consider their target area percentile values for the nation, jurisdiction and state. Percentile values at or above the 80 th percentile indicate that the HHA is at risk for improper Medicare payments. Providers should place the highest HHA PEPPER User s Guide, First Edition 8
priority with their national percentile, as this percentile represents how the HHA compares to all HHAs in the nation. Percentile values at or above the jurisdiction 80 th percentile or state 80 th percentile should be considered as well, but with a lower priority. Jurisdiction and state are smaller comparison groups, and therefore the percentiles may be less meaningful. In addition, there may be regional differences in practice patterns reflected in jurisdiction and state percentiles. The Sum of Payments and Target Count (where available) can also be used to help prioritize areas for review. Areas in which a provider is at/above the 80 th percentile that have a high sum of payment and/or numerator count may be given higher priority than target areas for which a provider is at/above the 80 th percentile that have a lower sum of payments/numerator count. Target Area Reports PEPPER Target Area Reports display a variety of statistics for each target area summarized over three years. Each report includes a target area graph, a target area data table, comparative data, interpretive guidance and suggested interventions. Target Area Graph Each report includes a target area graph, which provides a visual representation of the HHA s target area percent or rate over three years. The HHA s data is represented on the graph in bar format, with each bar representing a calendar year. HHAs can identify changes in the target area percent/rate from one time period to the next, which could be a result of, for example, changes in patient population, medical/therapy staff or utilization review processes. HHAs are encouraged to identify root causes of major changes to ensure that improper payments are prevented. Note: HHRG case mix weights changed (decreased) in CY 2014 from CY 2013; therefore providers should expect to see a decrease for the CY2014 time period. The graph includes red trend lines for the percents/rates that are at the 80 th percentile for the three comparison groups (nation, jurisdiction and state) so the HHA can easily identify when its results suggest that it is at risk for improper Medicare payments when compared to any of these groups. A table of these values ( Comparative Data ) is included under the HHA s data table. For more information on percents versus percentiles, see the Training and Resources page in the HHA section on PEPPERresources.org for a short slide presentation with visuals to assist in the understanding of these terms. An HHA s data will not be displayed in the graph if the numerator count for the target area is less than 11 for any time period. This is due to data restrictions established by CMS. If there are fewer than 11 HHAs with reportable data for a target area in a state for any time period, there will not be a data point/trend line for the state comparison group in the graph. If there are fewer than 11 HHAs with reportable data for a target area in a jurisdiction for any time period, there will not be a data point/trend line for the jurisdiction comparison group in the graph. HHA PEPPER User s Guide, First Edition 9
Target Area HHA Data Table PEPPER Target Area Reports also include an HHA data table. Statistics in each data table include the target (numerator) count for the target area, the denominator count, the proportion of the numerator and denominator (percent or rate), average length of stay for the numerator and for the denominator (where available), and the average and sum of Medicare payment data (where available). For the Average Case Mix target area, the numerator average length of stay, the average Medicare payments and sum of Medicare payments cannot be calculated for the numerator, which is the sum of case mix weights for episodes paid to the HHA during the report period (excluding LUPAs and PEPs). For the Average Number of Episodes target area, the denominator average length of stay cannot be calculated because the denominator is the count of unique beneficiaries served by the HHA during the report period. For the Outlier Payments target area, the average and sum of Medicare payments are not reported, to avoid duplication in reporting these measures. The HHA s percent/rate will be shown in red bold print if it is at or above the national 80 th percentile (suggesting a risk of improper Medicare payments). (See Percentile in the Glossary, page 13.) For each time period, an HHA s data will not be displayed if the numerator count for the target area is less than 11. Comparative Data Table The Comparative Data Table provides the target area percents/rates that are at the 80 th percentile for the three comparison groups of nation, jurisdiction and state. These are the values that are graphed as red trend lines on the Target Area Graph. State percentiles are zero when there are fewer than 11 HHAs with reportable data for a target area in the state. Jurisdiction percentiles are zero when there are fewer than 11 HHAs with reportable data for a target area in the jurisdiction. Interpretive Guidance and Suggested Interventions Interpretive guidance is included on the target area report (to the left of the graph) to assist HHAs in considering whether they should audit a sample of records. Suggested interventions for providers, whose results suggest a risk for improper Medicare payments, are tailored to each target area and are included at the bottom of each report. HHA Top Diagnoses Report The HHA Top Diagnoses report lists the top Clinical Classifications Software (CCS) diagnosis categories 6 (up to 20) for episodes at the HHA ending in the most recent calendar year. For each diagnosis category listed, the report includes the total number of episodes that have a principal diagnosis code mapping to that category, the proportion of episodes for the diagnosis category to total episodes, the number of visits and the average number of visits. Please note that this report is limited to displaying the 6 ICD-9 diagnoses and procedures have been collapsed into general categories using Clinical Classification Software (CCS). More information on CCS can be found at http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp HHA PEPPER User s Guide, First Edition 10
top diagnosis categories (up to 20) for which there are a total of at least 11 episodes ending in the most recent calendar year. HHA Top Therapy Episodes Report The HHA Top Therapy Episodes report lists the top CCS diagnosis categories (up to five) for five groups of episodes: Early 0-13 therapy visits episodes, Early 14-19 therapy visits episodes, Late 0-13 therapy visits episodes, Late 14-19 therapy visits episodes and All 20+ therapy visits episodes for episodes at the HHA ending in the most recent calendar year. Note: Episodes are categorized into a therapy episode group based on the first digit in the HIPPS code as reported on the claim. For each therapy group the report includes the number of episodes, the proportion of all episodes, the total number of therapy visits and the average number of therapy visits for the HHA for the most recent calendar year. The top diagnosis categories (up to five) for each therapy group are listed, along with the number of episodes for the diagnosis category, the proportion of episodes for the diagnosis category within each therapy group, the number of therapy visits and the average number of therapy visits. Please note that this report is limited to displaying statistics for the therapy groups and/or diagnosis categories for which there were at least 11 episodes ending in the most recent calendar year. Jurisdiction-wide Top Diagnoses Report The Jurisdiction-wide Top Diagnoses report lists the top CCS diagnosis categories (up to 20) for episodes in the MAC jurisdiction ending in the most recent calendar year. For each diagnosis category listed, the report includes the total number of episodes that have a principal diagnosis code mapping to that category, the proportion of episodes for the diagnosis category to total episodes, the number of visits and the average number of visits. Jurisdiction-wide Top Therapy Episodes Report The Jurisdiction-wide Top Therapy Episodes report lists the top CCS diagnosis categories (up to five) for five groups of therapy episodes: Early 0-13 therapy visits episodes, Early 14-19 therapy visits episodes, Late 0-13 therapy visits episodes, Late 14-19 therapy visits episodes and All 20+ therapy visits episodes for episodes in the MAC jurisdiction ending in the most recent calendar year. For each therapy group the report includes the number of episodes, the proportion of all episodes, the total number of therapy visits and the average number of therapy visits in the MAC jurisdiction for the most recent calendar year. The top diagnosis categories (up to five) for each therapy group are listed, along with the number of episodes for the diagnosis category, the proportion of episodes for the diagnosis category within each therapy group, the number of therapy visits and the average number of therapy visits. System Requirements, Customer Support and Technical Assistance PEPPER is a Microsoft Excel workbook that can be opened and saved to a personal computer (PC). It is not intended for use on a network but may be saved to as many PCs as necessary. For help using PEPPER, please submit a request for assistance at PEPPERresources.org by clicking on the Help/Contact Us tab. This website also provides many educational resources to assist HHAs with PEPPER in the HHA Training and Resources section. HHA PEPPER User s Guide, First Edition 11
Please do not contact your Medicare Quality Improvement Organization or any other association/organization for assistance with PEPPER, as these organizations are not involved in the production or distribution of PEPPER. HHA PEPPER User s Guide, First Edition 12
Glossary Average Length of Stay The average length of stay (ALOS) is calculated as an arithmetic mean. It is computed by dividing the total number of days on claims ending during the report period at the HHA by the total number of claims submitted by the HHA during the time period. Calendar The calendar year begins January 1 and ends December 31. Year Data Table Episode Graph Length of Stay Percentile The statistical findings for a HHA are presented in tabular form, labeled by time period and indicator. For HHAs an episode is synonymous with a claim. In PEPPER, a graph shows a HHA s percentages for three years. The HHA s percentages are compared to the 80 th percentiles for the nation, jurisdiction and state for all target areas. See Percentile. The length of stay (LOS) is the total number of HHA days for claim submitted by a HHA for a beneficiary s episode. It is computed by subtracting the admission date (From Date) of the claim from the discharge date (Through Date) of the claim, plus one. In PEPPER, the percentile represents the percent of HHAs in the comparison group below which a given HHA s percent/rate value ranks. It is a number that corresponds to one of 100 equal divisions of a range of values in a group. The percentile represents the HHA s position in the group compared to all other HHAs in the comparison group for that target area and time period. For example, suppose a HHA has a target area percent/rate of 2.3, and 80 percent of the HHAs in the comparison group have a percent/rate for that target area that is less than 2.3. Then we can say the HHA is at the 80 th percentile. Percentiles in PEPPER are calculated from the HHAs percents/rates so that each HHA s percent/rate can be compared to the national, jurisdiction-wide or statewide distribution of HHA percents/rates. For more on percents versus percentiles, please see the Training and Resources page in the HHA section on PEPPERresources.org for a short slide presentation with visuals to assist in the understanding of these terms. Rate The quantity or amount of one measure (numerator) considered in relation to a unit of another measure (denominator); not reported as a percent. HHA PEPPER User s Guide, First Edition 13
Acronyms and Abbreviations ACRONYM/ ABBREVIATION ALOS CMS FATHOM LOS MAC PEPPER TMF UB-04 ACRONYM/ABBREVIATION DEFINITION The average length of stay (ALOS) is calculated as an arithmetic average, or mean. It is computed by dividing the total number of days on claims ending during the report period at the HHA by the total number of claims submitted by the HHA during the time period. The Centers for Medicare & Medicaid Services (CMS) is the federal agency responsible for oversight of Medicare and Medicaid. CMS is a division of the U.S. Department of Health and Human Services. First-look Analysis Tool for Hospital Outlier Monitoring (FATHOM) is a Microsoft Access application. It was designed to help Medicare Administrative Contractors (MACs) compare acute care prospective payment system (PPS) inpatient hospitals in areas at risk for improper payment using Medicare administrative claims data. The length of stay (LOS) is the total number of HHA days for the claim submitted by anhha for a beneficiary s episode. It is computed by subtracting the admission date (From Date) on the claim from the discharge date (Through Date) of the claim, plus one. The Medicare Administrative Contractor (MAC) is the contracting authority that replaced the fiscal intermediary (FI) and carrier in performing Medicare Fee-For- Service claims processing activities. Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a data report that contains a single provider s claims data statistics for claims for service at risk for improper Medicare payments. TMF Health Quality Institute (TMF) is under contract with the Centers for Medicare & Medicaid Services (CMS) to develop and distribute PEPPER to short-term and longterm acute care hospitals, critical access hospitals, inpatient psychiatric and rehabilitation facilities, home health agencies, hospices, partial hospitalization programs and skilled nursing facilities, and to develop and distribute FATHOM to CMS and MACs. Standard uniform bill used by health care providers to submit claims for services. Claims for Medicare reimbursement are submitted to the provider s Medicare Administrative Contractor. HHA PEPPER User s Guide, First Edition 14